Lactational Amenorrhea: Neuroendocrine Pathways Controlling Fertility and Bone Turnover

Prioritise safety, optimise success! Return to rugby postpartum

Pregnancy and childbirth involve substantial physical, physiological and psychological changes. As such, postpartum rugby players should be supported and appropriately prepared to return to the demands of rugby alongside the additional demands of motherhood. This review aims to discuss specific perinatal considerations that inform a rugby player's readiness to return-to-sport postpartum and present an approach to rehabilitation. Before engaging in full rugby training and matchplay, postpartum players should have progressed through the initial phases of rehabilitation and graded sports-specific training to prepare them for the loads they will be exposed to. Additional rehabilitation considerations include minimising deconditioning during pregnancy; medical concerns; the abdominal wall; the pelvic floor; perinatal breast changes, breastfeeding and risk of contact breast injury; body mass; nutritional requirements; hormonal considerations; athlete identity and psychological considerations; joining team training; return to contact and tackle training; evaluating player load tolerance and future research, policy and surveillance needs. A whole-systems, biopsychosocial approach following an evidence informed return-to-sport framework is recommended when rehabilitating postpartum rugby players. Health and exercise professionals are encouraged to use the perinatal-specific recommendations in this review to guide the development of postpartum rehabilitation protocols and resources.

Current Insights in Prolactin Signaling and Ovulatory Function

Prolactin (PRL) is a pleiotropic hormone released from lactotrophic cells of the anterior pituitary gland that also originates from extrapituitary sources and plays an important role in regulating lactation in mammals, as well as other actions. Acting in an endocrine and paracrine/autocrine manner, PRL regulates the hypothalamic-pituitary-ovarian axis, thus influencing the maturation of ovarian follicles and ovulation. This review provides a detailed discussion of the current knowledge on the role of PRL in the context of ovulation and ovulatory disorders, particularly with regard to hyperprolactinemia, which is one of the most common causes of infertility in women. Much attention has been given to the PRL structure and the PRL receptor (PRLR), as well as the diverse functions of PRLR signaling under normal and pathological conditions. The hormonal regulation of the menstrual cycle in connection with folliculogenesis and ovulation, as well as the current classifications of ovulation disorders, are also described. Finally, the state of knowledge regarding the importance of TIDA (tuberoinfundibular dopamine), KNDγ (kisspeptin/neurokinin B/dynorphin), and GnRH (gonadotropin-releasing hormone) neurons in PRL- and kisspeptin (KP)-dependent regulation of the hypothalamic-pituitary-gonadal (HPG) axis in women is reviewed. Based on this review, a rationale for influencing PRL signaling pathways in therapeutic activities accompanying ovulation disorders is presented.

Postpartum family planning uptake in Uganda: findings from the lot quality assurance sampling survey

BACKGROUND

The initiation and use of family planning (FP) services within the first 12 months following childbirth, postpartum family planning (PPFP), promotes safe motherhood by reducing unintended pregnancies and ensuring appropriate pregnancy spacing. However, there is a paucity of information on PPFP uptake from community surveys. This study aimed to quantify the reported use of PPFP and identify predictors and barriers to PPFP uptake from a large community survey.

METHODS

We analysed data collected from the 2021 Lot Quality Assurance Sampling (LQAS) survey, a cross-sectional community and household survey that covered 68 districts in Uganda. The survey uses small sample sizes to designate health or administrative geographical areas which are assessed to determine whether they achieved the pre-determined target for defined indicators of interest. We abstracted and analysed data collected from mothers of children aged 12 months or younger on reproductive health and FP. PPFP use was defined as the reported use of modern FP by the mother or their partner. Associations were measured using Pearson's chi-square test at 5% significance. Multivariate logistic regression was performed for variables that were significantly associated with PPFP use to identify the predictors of PPFP.

RESULTS

Overall, 8103 mothers of children aged less than 12 years were included in the analysis; the majority of mothers, 55.8% (4521/8103) were above 24 years while 11.7% (950/8103) were 19 years and under. 98% (7942/8103) of the mothers attended at least one antenatal care (ANC) visit and 86.3% (6997/8103) delivered at a health facility. Only 10% (814/8103) of mothers who participated in the survey reported PPFP use at the time of the survey. Reporting of PPFP use was 5 times higher among mothers of children aged 7-12 months (AOR 4.9; 95%CI 4.1-5.8), 50% higher among mothers with secondary education (AOR 1.5; 95%CI 1.0-2.3), 80% higher among breastfeeding mothers (AOR 1.8; 95%CI 1.3-2.4) and 30% lower among those that didn't receive a health worker visit within 3 months preceding the survey (AOR 0.7; 95% CI 0.5-0.8). Among 4.6% (372/8103) who stated a reason for non-use of PPFP, the most cited reasons for not using were breastfeeding 43% (161/372), fear of side effects 26.9% (100/372), respondent/partner opposition 17.6% (48/372) and infrequent sex 12.1% (48/372).

CONCLUSION

The analysis showed a low proportion of PPFP uptake among mothers of children under 12 years. Possible barriers included child age, education, a health worker visit, and side effects and perceived benefits of possibly improperly implementing lactation amenorrhea method. Integration of social, community and health services could provide a more holistic approach to improving PPFP uptake.

Pregnancy- and lactation-associated osteoporosis in the mother after the first and second children: A case report

INTRODUCTION

This study reports an unusual experience of a mother who may have developed birth-related osteoporosis after each of the births of her two children.

PRESENTATION OF CASE

A 31-year-old woman presented with lumbar back pain. She had given birth to her first child through vaginal delivery 4 months prior and was breastfeeding. Magnetic resonance imaging showed multiple fresh vertebral fractures, but continued breastfeeding resulted in further loss of bone density. The bone mineral density recovered after weaning. The patient gave birth to a second child three years after the first child's birth. She opted to discontinue breastfeeding after the detection of repeated instances of significant bone loss. No new vertebral fractures have occurred in the 9 years since the patient's initial visit to our clinic.

DISCUSSION

We describe a case where a mother experienced multiple episodes of rapid bone loss following childbirth. Bone health evaluation at an early stage following childbirth may be effective for preventing future bone fractures.

CONCLUSION

It is desirable to develop a team and guidelines for treating osteoporosis associated with pregnancy and lactation and for the next pregnancy and delivery.

Associated Factors of Exclusive Breastfeeding Intention among Pregnant Women in Najran, Saudi Arabia

The exclusive breastfeeding (EBF) intention conceived by pregnant women is the most important predictor of breastfeeding (BF) initiation, duration, and continuation. This study explores the associated factors of EBF intention among pregnant women. This was a descriptive cross-sectional study conducted from November 2022 to January 2023 with 382 pregnant women who came to the outpatient clinic in the Maternal and Children Hospital (MCH). Four instruments were used for data collection: the Infant Feeding Intention scale, the Gender-Friendly BF Knowledge scale (GFBKS), the Iowa Infant Feeding Attitude scale (IIFAS), and the basic data questionnaire. The study findings indicated that 51.8% and 75.9% of gravida women had adequate knowledge and a positive attitude regarding BF. Furthermore, 56.3% of the participants had a high intention for EBF. Binary logistic regression illustrated that occupational status, antenatal care, plan for the current pregnancy, BF practice, last child delivery mode, medical disorder during the current pregnancy, age, BF knowledge, and attitude are potential predictors. The goodness of fit test revealed that 46.8% of the EBF intention could be anticipated through the positive pre-mentioned factors. The low EBF intention is modifiable by addressing the previously positive predictors. BF educational interventions should be tailored based on EBF intention predictors in order to be effective and lead to behavior change.

Bridging the Gap: Pregnancy-And Lactation-Associated Osteoporosis

Early diagnosis of pregnancy- and lactation-associated osteoporosis (PLO) is mandatory for a good outcome. Standard care is not a matter of conventional guidelines, rather it requires an individualized strategy while true overall incidence and pathogeny remain open issues. This is a narrative review based on full-length English articles, published between January 2021 and March 2023 and accessed via PubMed (no traumatic fractures or secondary osteoporosis are included). Our case-sample-based analysis included 836 females with PLO (the largest cohort based on published cases so far) through 12 studies and 24 single case reports. Except for one survey, these involved retrospective cohorts of small size (6-10 females/study) to medium size (23-47 women/study), and large cohorts with >50 subjects per study (a maximum of 379). Age of diagnosis: from 24 to 40 years for case reports (most subjects being over 30 and primigravida), while original studies indicated an average age between 31 and 34.18 years. Type of fractures underlined a most frequent vertebral phenotype (a mean of 2 to 5.8 vertebral fractures per patient) versus a most severe non-vertebral phenotype (hip and femoral neck fractures mostly requiring surgery). Potential contributors varied: smoking (1/3-1/2 of subjects), family history of osteoporosis (1/3), heparin and glucocorticoid use in pregnancy, low body mass index (majority of cases), hypovitaminosis D; and (with a low level of statistical significance) anti-psychotic medication, gestational diabetes, lupus, thrombophilia, anemia, in vitro fertilization (1/3 in one study), twin pregnancy, tocolysis with MgSO4, and postpartum thyroiditis. Most remarkably, up to 50% of PLO patients harbor mutations of LRP5, WNT1, and COL1A1/A2 (more damaged form with potential benefits from osteoanabolic drugs); gene testing might become the new norm in PLO. The low index of clinical suspicion should be supported by performing magnetic resonance imaging (gold standard in pregnancy) with DXA (in lactation). Low bone mineral density is expected (Z-score varying from -2.2 SD to -4 SD, unless normal which does not exclude PLO). Bone turnover markers might be useful in individuals with normal DXA, in pregnancy when DXA cannot be performed, and in following the response to anti-osteoporosis drugs. Alternatively, microarchitecture damage might be reflected by DXA-trabecular bone score and high-resolution peripheral quantitative computed tomography. Specific medical interventions are currently focused on teriparatide (TPT) use (3 studies; n = 99 females treated with TPT and an additional subgroup of 18 patients from the gene-analysis-based study, thus a total of 117 females) which seems to be the therapy of choice as reflected by these new data: 6-24 months, 20 µg/day, no sequential therapy needed; case selection based on high fracture risk is necessary). The first case using romosozumab was reported in 2022. PAO/LAO remains a challenging condition which is a battle for the wellbeing of two individuals, on one hand, considering maternal-fetal outcomes and taking care of the offspring, but it is a battle for a multidisciplinary team, on the other hand, since a standardized approach is lacking.

Determinants of High Breastfeeding Self-Efficacy among Nursing Mothers in Najran, Saudi Arabia

Many factors have been found to correlate with satisfactory Exclusive Breastfeeding (EBF) practices. The relationships between EBF practices and associated factors are complex and multidimensional; Breastfeeding Self-Efficacy (BSE) is the most important psychological factor that may help the mother to overcome any expected barriers. This study investigates the determinants of high breastfeeding self-efficacy among Saudi nursing mothers.

METHODS

This is a descriptive cross-sectional study investigating the determinant of BSE among 1577 nursing mothers in primary health centers in Najran City, Saudi Arabia. The study uses a cluster random sampling technique. Data collection was performed from June 2022 to January 2023 using a self-reported questionnaire that encompasses the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), Gender Friendly Breastfeeding Knowledge Scale (GFBKS), Iowa Infant Feeding Attitude Scale (IIFAS), and a basic data questionnaire to assess women's demographic factors and obstetric history.

RESULTS

The mean score for all BSES-SF items was between 3.23-3.41, the highest mean score was in mothers who felt comfortable breastfeeding with family members present (3.41 ± 1.06), and the lowest mean was in mothers who could breastfeed their baby without using formula as a supplement (3.23 ± 0.94). The overall BSE score was high among 67% of the study participants. Binary logistic regression showed that being a housewife, being highly educated, having breastfeeding experience, and being multiparous are positive predictors for high BSE (p ≤ 0.001). In addition, having adequate breastfeeding knowledge and positive breastfeeding attitudes were positively associated with higher BSE (p = 0.000).

CONCLUSION

BSE can be predicted by modifiable predictors such as mothers' education, working status, parity, breastfeeding experience, adequate breastfeeding knowledge, and positive attitudes toward breastfeeding. If such predictors are considered during breastfeeding-related educational interventions, it could lead to more effective and sustainable effects in community awareness regarding breastfeeding.

Breastfeeding history and adenomyosis risk using a novel case-control study design

OBJECTIVE

To evaluate the association between breastfeeding history, including lifetime exclusive breastfeeding, and risk of adenomyosis.

DESIGN

We used data from a case-control study designed with 2 control groups to address the challenge of selecting noncases for a valid epidemiologic study when cases are identified by hysterectomy. The case-control study was conducted among premenopausal and postmenopausal enrollees aged 18-59 years in a large, integrated health care system in western Washington state.

PATIENT(S)

Cases were enrollees with incident, pathology-confirmed adenomyosis diagnosed during 2001-2006 (n = 386). The 2 control groups were as follows: (1) randomly selected age-matched enrollees with intact uteri ("population controls," n = 323) and (2) hysterectomy controls (n = 233).

INTERVENTION(S)

Data on breastfeeding history were collected by in-person interviews. For each reported live birth, participants were asked whether they breastfed, along with infant age at supplemental feeding introduction and breastfeeding discontinuation.

MAIN OUTCOME MEASURE(S)

Among participants with at least 1 live birth (330 cases, 246 population controls, and 198 hysterectomy controls), we used unconditional logistic regression to estimate adjusted odds ratios and 95% confidence intervals (CIs) for the associations between the following: (1) ever breastfeeding, (2) ever breastfeeding for ≥8 weeks, (3) lifetime breastfeeding, and (4) lifetime exclusive breastfeeding and risk of adenomyosis. Analyses were adjusted for age, reference year, smoking, education, and parity.

RESULT(S)

In analyses comparing cases with population controls, we observed a 40% decreased odds of adenomyosis with a history of ever breastfeeding (adjusted odds ratio, 0.6; 95% CI, 0.3-1.0) and breastfeeding for ≥8 weeks (adjusted odds ratio, 0.6; 95% CI, 0.4-0.8). The strongest associations, 60%-70% decreased odds of adenomyosis, were observed with ≥12 months of lifetime breastfeeding (vs. <3 months) (adjusted odds ratio, 0.4; 95% CI, 0.2-0.6) and 9 to <12 months of lifetime exclusive breastfeeding (vs. <3 months) (adjusted odds ratio, 0.3; 95% CI, 0.2-0.6), comparing cases to population controls. In analyses using hysterectomy controls, we observed similar patterns of associations slightly attenuated in magnitude.

CONCLUSION(S)

Breastfeeding history was associated with a 40% decreased odds of adenomyosis, a condition that can confer substantial morbidity and requires hysterectomy for definitive treatment. The consistency of our findings with that of a previous study lends support that breastfeeding may modify risk of adenomyosis.

Sudden Death Due to Rupture of Ectopic Pregnancy in a Young Lactating Mother

The incidence of ectopic pregnancy in India is increasing over time along with a considerable mortality rate. The common site for ectopic pregnancy is the fallopian tubes and is also associated with a higher incidence of mortality following the tubal rupture. Even though lactational amenorrhea prevents pregnancy to some extent, the probability of pregnancy increases when the frequency of lactation decreases. Rupture of ectopic pregnancy can occur abruptly without any serious symptoms as well. One should not ignore even mild symptoms in females of reproductive age group especially those who are sexually active. A 25-year-old female with an alleged history of sudden onset of severe abdominal pain was taken to AIIMS Bhopal, where she was declared brought dead and her body was sent for autopsy. She got married at the age of 23 years and was still breastfeeding her 11-month-old child. The autopsy revealed 2.2 liters of fluid and clotted blood in the peritoneal cavity. The right fallopian tube enlarged along with a tear of size 1cm x 1cm evident on the anterior aspect. Meticulous dissection revealed a membranous sac of size 4cm x 2cm x 2cm containing a placenta of size 1cm x 1cm and an embryo of size 2cm x 1cm. All other organs were pale and normal. The uterine cavity was found empty. The cause of death was attributed to ruptured ectopic pregnancy.

Effects of undernutrition and low energy availability on reproductive functions and their underlying neuroendocrine mechanisms

It has been well established that undernutrition and low energy availability disturb female reproductive functions in humans and many animal species. These reproductive dysfunctions are mainly caused by alterations of some hypothalamic factors, and consequent reduction of gonadotrophin-releasing hormone (GnRH) secretion. Evidence from literature suggests that increased activity of orexigenic factors and decreased activity of anorexigenic/satiety-related factors in undernourished conditions attenuate GnRH secretion in an integrated manner. Likewise, the activity of kisspeptin neurons, which is a potent stimulator of GnRH, is also reduced in undernourished conditions. In addition, it has been suggested that gonadotrophin-inhibitory hormone, which has anti-GnRH and gonadotrophic effects, may be involved in reproductive dysfunctions under several kinds of stress conditions. It should be remembered that these alterations, i.e., promotion of feeding behavior and temporary suppression of reproductive functions, are induced to prioritize the survival of individual over that of species, and that improvements in metabolic and nutritional conditions should be considered with the highest priority.