Imaging Findings of Ovarian Vein Thrombosis

Ovarian vein thrombosis (OVT) is an uncommon condition that occurs mainly in the peripartum period. Hyper-coagulable conditions have been reported to cause OVT outside the peripartum period. The clinical presentation is usually nonspecific pain, but it can be asymptomatic in patients with underlying malignancy. Imaging plays an important role in diagnosis. Ultrasound is the initial imaging modality, but it is operator-dependent and has limited sensitivity. Computed tomography (CT) is the most commonly used modality for diagnosis. CT can show the luminal filling defect within the thrombosed vein and assess the extension of the thrombosis. MRI can show the thrombosed vein as a filling defect on post-contrast images; also, diffusion-weighted images may help in the diagnosis. Complications include extension into the inferior vena cava or renal veins. Pulmonary embolism is the most serious complication. Treatment includes anticoagulation plus antibiotics. Early diagnosis is essential to prevent complications.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part II: Non-Obstetric Complications

Emergency imaging in pregnancy and puerperium poses unique challenges both for clinicians and radiologists, requiring timely and accurate diagnosis. Delay in treatment may result in poor outcomes for both the patient and the foetus. Pregnant and puerperal patients may present in the emergency setting with acute abdominopelvic pain for various complications that can be broadly classified into obstetric and non-obstetric related diseases. Ultrasonography (US) is the primary diagnostic imaging test; however, it may be limited due to the patient's body habitus and the overlapping of bowel loops. Computed tomography (CT) carries exposure to ionising radiation to the foetus, but may be necessary in selected cases. Magnetic resonance imaging (MRI) is a valuable complement to US in the determination of the etiology of acute abdominal pain and can be used in most settings, allowing for the identification of a broad spectrum of pathologies with a limited protocol of sequences. In this second section, we review the common non-obstetric causes for acute abdominopelvic pain in pregnancy and post partum, offering a practical approach for diagnosis and pointing out the role of imaging methods (US, MRI, CT) with the respective imaging findings.

Beyond Postpartum Fever: Case Report Uncovering Deep Septic Pelvic Thrombophlebitis

Deep septic pelvic thrombophlebitis (DSPT) is a rare postpartum condition that should be considered in the setting of postpartum fever and may prove to be a challenging diagnosis. Here, we report the case of a 26-year-old female who presented with fever and antibiotic-resistant leukocytosis following an uncomplicated cesarean delivery. After ruling out pulmonary embolism and other causes of septicemia and considering the overall negative imaging studies, the patient received a clinical diagnosis of DSPT and recovered well following antibiotic augmentation and anticoagulation.

A Perfect Storm: Ventricular Fibrillation Cardiac Arrest Due to Acute Myocardial Infarction Seen in the Postpartum Period in the Setting of COVID

Acute myocardial infarction (AMI) in women of reproductive age is uncommon; however, the risk of AMI increases four to five-fold during pregnancy as compared to non-pregnant women of similar age. In the period following childbirth, the incidence of AMI is often attributed to a range of factors. These factors encompass coronary vessel dissection related to atherosclerosis, thrombosis, coronary spasm, and, in rare cases, takotsubo cardiomyopathy. The physiological alterations that accompany pregnancy induce a state of heightened coagulation, thereby elevating the risk of ischemic heart disease (IHD) in women. While the presence of traditional risk factors is not a strong predictor of post-partum AMI (PAMI) due to any cause, most cases of PAMI due to IHD or atherosclerosis have other mechanisms associated with AMI, significant past medical history, or the presence of other traditional risk factors. The purpose of this report is to describe an uncommon case of pregnancy associated with MI due to ischemic heart disease and discuss the pathogenesis of contributing risk factors that created the "perfect storm" leading to her presentation.

Chyluria in a Postpartum Obese Female Patient

Chyluria characterized by the passage of milky white urine is rarely encountered these days due to the overall reduction in the number of cases of lymphatic filariasis. Though lymphatic filariasis accounts for the majority of cases of chyluria, nonparasitic causes have also been reported. Case reports of chyluria as a complication in pregnancy have been published but chyluria presenting solely as a postpartum complication has rarely been documented. We present a case of a 29-year-old female with no known prior comorbidities, who presented with recurring complaints of the painless passage of milky white urine over the last year. Symptoms seem to have started six months post-delivery of her second child. The patient claimed significant weight gain during an otherwise normal pregnancy. She was well-built and had a BMI of 32 kg/m². Her systemic examination and baseline laboratory workup were within normal limits. Postprandial urine was milky white, rich in chylomicrons, with urine chylomicrons of 112 mg/dl. The patient was screened for filariasis, which was negative. An ultrasound of the abdomen was done to rule out the presence of a fistula, but no evidence of one was found on imaging. Tc-99m sulfur colloid scintigraphy revealed an area of abnormal tracer accumulation in the abdomen with the passage of the tracer in the urine container, confirming the presence of chyluria. The patient was recommended to undergo conservative management with dietary modification and weight reduction. She has been closely followed up and has achieved spontaneous resolution of the chyluria. Most patients with chyluria show a good response to conservative management alone as in our case. Surgical intervention is usually indicated for cases not responding to conservative management or for refractory chyluria.

Spontaneous Coronary Arterial Dissection in a Young Female in the Postpartum Period: A Case Report From Sub-Saharan Africa

Spontaneous coronary arterial dissection (SCAD) has become an important cause of acute coronary syndrome (ACS) and sudden cardiac death, particularly in young women, without classic atherosclerotic cardiovascular risk factors. Missed diagnosis is common due to a low index of suspicion in these patients. Here, we present a case of a 29-year-old African female in the postpartum period who presented with a two-week history of heart failure symptoms and acute onset chest pain. An electrocardiogram showed ST-segment elevation myocardial infarction (STEMI) with elevated high-sensitivity troponin T. Echocardiography on admission revealed an ejection fraction of 40% with septal hypokinesia. Coronary angiography showed multivessel dissection with type 1 SCAD in the left circumflex artery and type 2 SCAD in the left anterior descending artery. The patient was managed conservatively, and angiographic healing of SCAD together with normalization of the left ventricular systolic dysfunction was seen after four months. SCAD should always be in the differential diagnosis of any peripartum patient who presents with ACS and lacks the typical atherosclerotic risk factors. Accurate diagnosis and appropriate management are paramount in such cases.

Postpartum Idiopathic Pancreatitis Complicated by Acute Necrotizing Pancreatitis

Acute pancreatitis (AP) is a common medical condition with a wide variety of etiologies. One of the common but frequently undetected causes of acute pancreatitis is microlithiasis, which can appear as biliary "sludge" in the gallbladder on imaging. While a broad workup should be initiated, endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the diagnosis of microlithiasis. In this case, we present a severe presentation of acute pancreatitis in a teenager within the postpartum period. A 19-year-old woman presented with severe 10 out of 10 right upper quadrant (RUQ) pain with episodes of nausea that radiated to her back. She had no history of chronic alcoholism, illicit drug use, or over-the-counter supplement use, and no familial history of autoimmune disease, or pancreatitis. The patient was diagnosed with necrotizing acute pancreatitis with gallbladder "sludge" using contrast-enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP). She followed up with gastroenterology and had a great clinical recovery. Therefore, it is important to consider acute pancreatitis in patients with idiopathic pancreatitis in their postpartum period as they are prone to forming gallbladder "sludge" which can precipitate and cause a variation in gallbladder pancreatitis which can be difficult to detect on imaging.

Prediction of Maternal Hemorrhage Using Machine Learning: Retrospective Cohort Study

Background

Postpartum hemorrhage remains one of the largest causes of maternal morbidity and mortality in the United States.

Objective

The aim of this paper is to use machine learning techniques to identify patients at risk for postpartum hemorrhage at obstetric delivery.

Methods

Women aged 18 to 55 years delivering at a major academic center from July 2013 to October 2018 were included for analysis (N=30,867). A total of 497 variables were collected from the electronic medical record including the following: demographic information; obstetric, medical, surgical, and family history; vital signs; laboratory results; labor medication exposures; and delivery outcomes. Postpartum hemorrhage was defined as a blood loss of ≥1000 mL at the time of delivery, regardless of delivery method, with 2179 (7.1%) positive cases observed. Supervised learning with regression-, tree-, and kernel-based machine learning methods was used to create classification models based upon training (21,606/30,867, 70%) and validation (4630/30,867, 15%) cohorts. Models were tuned using feature selection algorithms and domain knowledge. An independent test cohort (4631/30,867, 15%) determined final performance by assessing for accuracy, area under the receiver operating curve (AUROC), and sensitivity for proper classification of postpartum hemorrhage. Separate models were created using all collected data versus models limited to data available prior to the second stage of labor or at the time of decision to proceed with cesarean delivery. Additional models examined patients by mode of delivery.

Results

Gradient boosted decision trees achieved the best discrimination in the overall model. The model including all data mildly outperformed the second stage model (AUROC 0.979, 95% CI 0.971-0.986 vs AUROC 0.955, 95% CI 0.939-0.970). Optimal model accuracy was 98.1% with a sensitivity of 0.763 for positive prediction of postpartum hemorrhage. The second stage model achieved an accuracy of 98.0% with a sensitivity of 0.737. Other selected algorithms returned models that performed with decreased discrimination. Models stratified by mode of delivery achieved good to excellent discrimination but lacked the sensitivity necessary for clinical applicability.

Conclusions

Machine learning methods can be used to identify women at risk for postpartum hemorrhage who may benefit from individualized preventative measures. Models limited to data available prior to delivery perform nearly as well as those with more complete data sets, supporting their potential utility in the clinical setting. Further work is necessary to create successful models based upon mode of delivery and to validate the findings of this study. An unbiased approach to hemorrhage risk prediction may be superior to human risk assessment and represents an area for future research.

General medical conditions and mortality in women with postpartum psychiatric disorders

BACKGROUND

Psychiatric patients have an increased risk of general medical conditions and mortality, but no study has systematically explored these outcomes among women with mental disorders following childbirth (postpartum psychiatric disorders: PPD). Therefore, we aimed to investigate the risk of subsequent general medical conditions and mortality in women with a broad spectrum of PPD.

METHODS

This register-based cohort study followed all Danish women born after January 1, 1960, until January 1, 2016. The exposure of interest was (i) mild-moderate PPD: first-ever prescription of psychotropic medication (ATC codes: N03-N07) and (ii) severe PPD: first-ever in- or out-patient contact to a psychiatric facility, both within six months postpartum. Outcomes of interest were (i) hospital-registered chronic medical conditions and (ii) mortality from natural and unnatural causes. We included 1 841 949 women representing 22 615 310 person-years at risk.

RESULTS

Among 15 852 women with mild-moderate PPD and 4266 women with severe PPD, we found a higher risk of any subsequent general medical condition (mild-moderate PPD: IRR 1.25; 95% CI 1.20-1.31 and severe PPD: IRR 1.35; 95% CI: 1.24-1.48) when compared to the female background population. Mortality from both natural and unnatural causes was higher in both groups: Mild-moderate PPD: natural causes MRR 1.37; 95% CI: 1.17-1.61; unnatural causes MRR 1.52; 95% CI: 1.10-2.11, and severe PPD: natural causes MRR 1.42; 95% CI 1.02-2.00, and unnatural causes MRR 5.05; 95% CI: 3.40-7.51.

CONCLUSIONS

This first overview of general medical prognosis in PPD shows that women at either end of the spectrum are at increased risk of subsequent chronic medical conditions and overall mortality.

Pharmacokinetics of Efavirenz 600 mg Once Daily During Pregnancy and Post Partum in Ghanaian Women Living With HIV

PURPOSE

The updated World Health Organization guidelines recommend efavirenz (EFV) 400 mg as the preferred alternate first-line antiretroviral therapy to dolutegravir, with EFV 600 mg recommended only in special situations. We examined the pharmacokinetic (PK) properties of EFV 600 mg/d during pregnancy and post partum to inform EFV dosing decisions in pregnant women.

METHODS

Ghanaian pregnant women with HIV infection initiating tenofovir disoproxil fumarate 300 mg/lamivudine 300 mg/EFV 600 mg fixed-dose combination tablet once daily were enrolled. Efavirenz concentrations were measured at 4 weeks of antiretroviral therapy initiation during pregnancy and 6 weeks post partum using validated LC-MS/MS assays. Efavirenz PK parameters were calculated using noncompartmental analysis, and within-group parameters between the 2 periods were compared.

FINDINGS

Of 25 enrolled women, 19 completed PK sampling during pregnancy and post partum. The C_max, C_min, AUC_0-24h, and CL/F for EFV during pregnancy were similar to values at 6 weeks post partum. The pregnancy/postpartum geometric mean ratios for EFV C_max, C_min, AUC_0-24, and CL/F were 1.10 (95% CI, 0.93-1.31), 0.88 (95% CI, 0.67-1.17), 0.84 (95% CI, 0.71-0.98), and 1.20 (95% CI, 1.02-1.40), respectively. Viral load suppression (HIV RNA <200 copies/mL) was achieved in 16 of 17 participants (94%) by the time of delivery. There was 1 maternal-to-child transmission.

IMPLICATIONS

We found that the PK parameters of EFV 600 mg once daily during pregnancy were similar to those in the postpartum period. Our findings suggest that EFV dose adjustment during pregnancy is not necessary in our study population.

[Observation on therapeutic effect of electroacpuncture combined with penetrating moxibustion for postpartum pelvic organ prolapse]

OBJECTIVE

To compare the clinical therapeutic effect of electroacupuncture (EA) combined with penetrating moxibustion and biofeedback electrical stimulation on postpartum pelvic organ prolapsed (POP).

METHODS

A total of 60 patients with POP who had delivery 6 weeks ago were randomized into an observation group and a control group, 30 cases in each one. In the observation group, EA was applied at Zigong (EX-CA 1), Ciliao (BL 32), Huiyang (BL 35), etc. while penetrating moxibustion was performed at acupoints of abdomen and lumbosacral region alternately every other day. In the control group, biofeedback electrical stimulation was provided. The treatment for 6 weeks was given once every other day, 3 times a week in both groups. Before treatment, after treatment and 6 months after delivery, pelvic floor muscle strength, pelvic organ prolapse quantification (POP-Q) evaluation and pelvic floor impact questionnaire short form-7 (PFIQ-7) were observed to assess the therapeutic effect.

RESULTS

Compared before treatment, the sustained contraction and rapid contraction force of pelvic floor muscle after treatment and 6 months after delivery were increased in both of the two groups (P<0.05), and the changes in the observation group were larger than those in the control group (P<0.05). After treatment and 6 months after delivery, the POP degree in the observation group was alleviated to the control group (P<0.05). Compared before treatment, the scores of PFIQ-7 after treatment and 6 months after delivery were reduced in the two groups (P<0.05), and the changes in the observation group were larger than those in the control group (P<0.05).

CONCLUSION

Electroacupuncture combined with penetrating moxibustion can strengthen the pelvic floor muscle contractility of patients with postpartum pelvic organ prolapse, and are superior to biofeedback electrical stimulation in improving the pelvic organ prolapse status and life quality.

Inflammation: friend or foe of bovine reproduction?

Inflammation is not only the first line of defense of the organism but is also required in many reproductive processes such as ovulation, corpus luteum development, luteolysis, uterine clearance after insemination and post partum. Nevertheless, if excessive or persistent, inflammation can switch from a positive mechanism to a deleterious process, impairing oocyte quality and embryo development. Not only uterine but also non genital inflammatory sites can depreciate reproductive performances, with a carry over effect of 2 to 4 months. Since the metabolic challenges of the peripartum transition period make difficult for the cow to control inflammation, dairy cows are frequently in a pro-inflammatory stage, suggesting that inflammation, rather than infection, is a limiting factor of fertility in modern dairy cows. Within the first week after calving, cows have to mount an intense inflammatory response to the bacterial invasion of the uterine cavity with the challenge of being able to switch it off in no more than 5-6 weeks. The absence of neutrophils on endometrial smear is associated with the highest success rate at insemination. Since a fine tuning – rather than an absence - of inflammation is required along the reproductive cycle, anti-inflammatory drugs do not allow any improvement of pregnancy rate, except in the specific case of embryo transfer. Appropriate management of the transition period (especially nutritional) and in a long term perspective, genetic selection contribute to improve the aptitude of cows to controls the intensity of inflammatory process.

Fathers make a difference: positive relationships with mother and baby in relation to infant colic

BACKGROUND

Maternal psychological factors like depression, anxiety and stress have been associated with infant fussiness or colic. However, little research exists on whether positive factors such as social support and the happiness of the mother-partner relationship are associated with lower rates of infant fussiness or colic.

OBJECTIVES

We investigated the association between infant colic and three types of maternal support: general maternal social support (during pregnancy and post partum), the happiness of the mother-partner relationship (during pregnancy and post partum) and partner involvement in caring for the newborn.

METHODS

Participants were 3006 women in the First Baby Study, a prospective study of the effect of mode of first delivery on subsequent childbearing. Women were interviewed by telephone during pregnancy and 1 month after first childbirth and asked about social support and if their baby had a variety of problems since birth, including 'Colic - crying or fussiness three or more hours a day'. Multivariable logistic regression models were used to model the association between maternal support and infant colic, controlling for confounders, including maternal race or ethnicity, insurance, marital status, smoking, mode of delivery, maternal post-partum depression, breastfeeding, other neonatal illnesses and newborn gestational age.

RESULTS

Infant colic was reported by 11.6% of new mothers. High general maternal social support (in comparison with low), measured during pregnancy, was associated with lower reported infant colic (adjusted odds ratio (AOR), 0.55, 95% confidence interval (CI), 0.40-0.75) and measured post partum (AOR, 0.51, 95% CI, 0.39-0.67); high relationship happiness (in comparison with low), measured during pregnancy (AOR, 0.71, 95% CI, 0.54-0.93), and measured post partum (AOR, 0.22, 95% CI, 0.12-0.40); and high partner involvement with newborn care (in comparison with low) (AOR, 0.60, 95% CI, 0.44-0.81).

CONCLUSION

Higher levels of maternal social support during pregnancy and post partum are associated with lower rates of maternal reported infant colic.

Phytosterols from Dunaliella tertiolecta Reduce Cell Proliferation in Sheep Fed Flaxseed during Post Partum

The post partum period is characterized by immunosuppression and increased disease susceptibility. Both phytosterols from microalga Dunaniella tertiolecta and dietary supplementation with n-3 polyunsaturated fatty acids (PUFA) influence cell proliferation and cytokine release during inflammation. The objective of this paper was the evaluation of the effects of physterols, extracted and purified from D. tertiolecta, on the in vitro immune responses of ewes supplemented with flaxseed during post partum. Twenty Comisana parturient ewes were divided in two balanced groups, and supplemented with flaxseed (FS, 250 g/day) or fed with a conventional diet (CON). Blood samples (15 mL) were collected for five weeks, starting from lambing, in order to isolate peripheral blood mononuclear cells (PBMC). Stimulated PBMC were treated with a total sterols fraction from D. tertiolecta (TS), a mix of ergosterol and 7-dehydroporiferasterol (purified extract, PE), and a mix of acetylated ergosterol and 7-dehydroporiferasterol (acetylated purified extract, AcPE), extracted and purified from D. tertiolecta at two concentrations (0.4 and 0.8 mg/mL). Results of the experiment demonstrated that n-3 PUFA from flaxseed induced an anti-inflammatory cytokine profile, with an increase of both IL-10, IL-6 and a decrease of IL-1β. TS, PE, and AcPE purified from D. tertiolecta showed an anti-proliferative effect on sheep PBMC regardless their chemical composition and concentration.

Development and Validation of a Questionnaire for the Assessment of Pelvic Floor Disorders and Their Risk Factors During Pregnancy and Post Partum

Introduction The aim of this study was to develop and validate a questionnaire for the assessment of pelvic floor disorders, their symptoms and risk factors in pregnancy and after birth including symptom course, severity and impact on quality of life. Methods The validated German pelvic floor questionnaire was modified and a new risk factor domain developed. The questionnaire was initially completed by 233 nulliparous women in the third trimester of pregnancy and at six weeks (n = 148) and one year (n = 120) post partum. Full pyschometric testing was performed. The clinical course of symptoms and the influence of risk factors were analysed. Results Study participants had a median age of 31 (19-46) years. 63 % had spontaneous vaginal deliveries, 15 % operative vaginal deliveries and 22 % were delivered by caesarean section. Content validity: Missing answers never exceeded 4 %. Construct validity: The questionnaire distinguished significantly between women who reported bothersome symptoms and those who did not. Reliability: Cronbach's alpha values exceeded 0.7 for bladder, bowel and support function, and 0.65 for sexual function. The test-retest analysis showed moderate to almost complete concordance. The intraclass coefficients for domain scores (between 0.732 and 0.818) were in acceptable to optimal range. Reactivity: The questionnaire was able to track changes significantly with good effect size for each domain. Risk factors for pelvic floor symptoms included familial predisposition, maternal age over 35 years, BMI above 25, nicotine abuse, subjective inability to voluntarily contract the pelvic floor musculature and postpartum wound pain. Conclusion This pelvic floor questionnaire proved to be valid, reliable and reactive for the assessment of pelvic floor disorders, their risk factors, incidence and impact on quality of life during pregnancy and post partum. The questionnaire can be utilised to assess the course of symptoms and treatment effects using a scoring system.

Postpartum uterine artery blood flow impedance following cesarean section or vaginal delivery

PURPOSE

To compare uterine arteries (UtA) blood flow after cesarean section (CS) or vaginal delivery (VD).

METHODS

We performed a prospective case-control study comparing UtA blood flow impedance in patients who delivered by CS or VD. The UtA pulsatility index (PI) was measured with Doppler ultrasound during post partum using a transabdominal convex probe. Maternal and gestational age, parity, gravidity, and delay between delivery and Doppler measurement were noted.

RESULTS

We examined 106 postnatal patients, of whom 35 had CS delivery and 71 had VD. The median delay from delivery to Doppler measurement was 35 hours for the CS group and 32 hours for the VD group. The mean PI following CS and VD was 1.62 ± 0.45 and 1.42 ± 0.47, respectively. Using a linear model, the regression coefficients for mean, right, and left PI were not significantly different depending on the mode of delivery. There was no difference between emergency and elective CS.

CONCLUSIONS

Early postpartum UtA blood flow impedance is not significantly different after CS or VD. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:278-283, 2016.

[Postpartum acute coronary syndrome secondary to spontaneous coronary dissection: report of a case]

L'IDM per gravidique est une complication grave qui entraine une morbidité et une mortalité maternelle élevée. Bien que l'athérosclérose soit la cause d'IDM la plus fréquente dans la population générale, elle n'est observée que chez un tiers des femmes enceintes. Chez ces dernières, la cause la plus fréquente d'IDM était la dissection coronaire. Nous rapportons l'observation clinique d'une jeune femme de 24 ans, sans facteur de risque cardiovasculaire, qui a présenté un IDM antérieur étendu 15 jours après un accouchement, en rapport avec une dissection de la partie proximale de l'artère inter ventriculaire antérieure. Le traitement de cette pathologie n'est pas consensuel, et peut faire appel, selon la présentation clinique et angiographique, au traitement médical, à une revascularisation par pontage aorto-coronaire avec une résection de l'hématome de la paroi artérielle, ou à l'angioplastie transluminale. Le pronostic semble assez favorable quoique controversé.

Changes in the faecal microbiota of mares precede the development of post partum colic

REASONS FOR PERFORMING STUDY

Disruptions in the gastrointestinal microbiota may trigger development of post partum colic.

OBJECTIVES

To determine the effects of the periparturient period on the faecal microbiome and identify associations between the faecal microbiota and post partum colic.

STUDY DESIGN

Longitudinal case-control study.

METHODS

Pre- and post partum faecal samples were collected from mares on 3 farms in central Kentucky. Next generation sequencing of the V4 region of the 16S rRNA gene was performed on samples from 13 mares that developed colic, 13 mares that did not display colic and 5 nonpregnant controls.

RESULTS

There were 4,523,727 sequences from 85 samples evaluated (mean ± s.d. 53,220 ± 29,160, range 8442-122,535). Twenty-five phyla were identified, although only Firmicutes, Verrucomicrobia, Actinobacteria and Proteobacteria were present at a relative abundance of 1% or greater. The faecal microbiota of late-term mares differed from nonpregnant mares, with differences in microbial community membership and structure but not the relative abundance of major phyla. There was limited impact of foaling and the post partum period on the faecal microbiome. Faecal samples obtained from mares prior to episodes of colic had significantly higher relative abundance of Proteobacteria (8.2%, P = 0.0006) compared with samples from mares that did not display colic (3.7%). All samples with a relative abundance of Firmicutes of ≤50% preceded colic, as did 6/7 (86%) samples with >4% Proteobacteria. Differences in microbiota membership and structure were also present between mares that developed large colon volvulus and matched controls that did not have colic. Sixty-one indicator operational taxon units were identified for the control (vs. volvulus) samples, and these were dominated by Lachnospiraceae (n = 38) and Ruminococcaceae (n = 8).

CONCLUSIONS

Foaling had minimal effects on the mares' faecal microbiota. Numerous differences in the faecal microbiota preceded colic. Associations between Firmicutes (particularly Lachnospiraceae and Ruminococcaceae) and Proteobacteria and development of colic could lead to measures to predict and prevent colic. The Summary is available in Chinese - see Supporting information.

An Overview of Risk Factors Associated to Post-partum Depression in Asia

Post partum depression (PPD) is an important complication of child-bearing. It requires urgent interventions as it can have long-term adverse consequences if ignored, for both mother and child. If PPD has to be prevented by a public health intervention, the recognition and timely identification of its risk factors is must. We in this review have tried to synthesize the results of Asian studies examining the risk factors of PPD. Some risk factors, which are unique to Asian culture, have also been identified and discussed. We emphasize on early identification of these risk factors as most of these are modifiable and this can have significant implications in prevention of emergence of post partum depression, a serious health issue of Asian women.

Treatment of Iron Deficiency with or without Anaemia with Intravenous Ferric Carboxymaltose in Gynaecological Practices - A Non-Interventional Study

In this multi-centre, prospective, non-interventional study, the effectiveness and tolerance of ferric carboxymaltose (ferinject®; FCM) was tested through use in standard gynaecological practice. In total, data from 273 patients was evaluated. 193 of these patients displayed iron deficiency anaemia (IDA), and 68 had iron deficiency without anaemia (ID). The reasons for the ID/IDA were hypermenorrhoea (HyM) (n = 170), post-partum condition (PP) (n = 53) or another indication (n = 53). The average age of the patients was 40 years old, with 8 % of them being vegetarians. Half of the patients had already been treated for anaemia, primarily with oral iron products (94 %). The primary, serious accompanying symptoms of anaemia were fatigue (72 %), lack of concentration (42 %), pale mucous membranes (42 %), headache (26 %) and sleep disorders (21 %). Only one patient did not show serious symptoms at the start of the study. The most frequent indications for parenteral therapy were the need for rapid iron substitution to reduce symptoms (> 70 %), followed by the lower effectiveness or intolerance of oral products (42 % each) as well as patients not completing the course of treatment with oral products (12 %). Patient information was collected at both the beginning and the end of the observation period, which lasted 15 weeks on average. FCM was most frequently administered via infusion (92 %; average infusion duration 21 minutes). Seven percent of patients received bolus injections. The average total iron dosage per patient was 788.7 mg (median 550 mg; range: 50-3000 mg); the median individual dosage was 500 mg (range: 50-1000 mg). The total dosage was, in most cases, administered through a single application (range: 1-10). Symptoms, blood values (Hb), iron stores (serum-ferritin [S-ferritin]) and transport iron (transferrin saturation [TSAT]) normalised to a large extent. In all subgroups, 92 % of women displayed a marked improvement in all of their symptoms. The average increase in Hb-value in the group as a whole was statistically significant, increasing from 10.5 to 13.0 g/dl. In the group with anaemia, the value increased from 9.9 to 13.3 g/dl, with 80 % of women reaching normal Hb-values. The average S-ferritin value increased by a statistically significant > 70 µg/L from 17.2 to 88.8 µg/l and the value for the TSAT increased from 16.3 % to 22.8 %. Seven patients reported experiencing side effects. None of the results were severe. Overall, as part of this non-interventional study for everyday routine in a gynaecological practice, a rapid improvement in symptoms accompanied by the rectification of iron deficiency and anaemia was shown with low occurrences of mild undesirable events, and therefore the data obtained from controlled clinical studies on the effectiveness and tolerance of intravenous ferric carboxymaltose could be confirmed.

Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study

OBJECTIVE

To evaluate the prevalence and predictors of anal incontinence (AI) in late pregnancy and 1 year after delivery.

DESIGN

Prospective population-based cohort study.

SETTING

Two maternity units in Norway 2009-2010.

POPULATION

Primiparae aged 18 years or over.

METHODS

Primiparae answered questions on the St. Mark's score about AI during the last 4 weeks of pregnancy. One year later, the same questionnaires were distributed by postal mail. Socio-economic and delivery-related data were obtained from hospital records.

MAIN OUTCOME MEASURES

Self-reported AI.

RESULTS

Answers on AI in late pregnancy were obtained from 1571 women, and 1030 responded 1 year later. Twenty-four per cent experienced one and 4.7% experienced three or more AI symptoms in late pregnancy. One year later, this was reduced to 19% and 2.2%, respectively. Multivariate logistic regression analyses were applied. Formed and loose stool incontinence were strongly associated at both time points. The main predictor of AI 1 year after delivery was AI in late pregnancy. Obstetric anal sphincter injury increased the risk of incontinence of stool and flatus (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.7-9.6) after delivery. Urgency was associated with greater age (OR, 1.8; 95% CI, 1.0-3.3) and operative delivery (OR, 2.0; 95% CI, 1.3-2.9).

CONCLUSION

One in four primiparae experienced AI in late pregnancy. One year later, still one in five suffered from incontinence. Sphincter injury predicted incontinence of stool and flatus, whereas greater age and operative delivery predicted urgency. The identification and adequate follow-up of pregnant women with AI may reduce AI after delivery.

Pregnancy and puerperium-related strokes in Asian women

BACKGROUND

Despite an increased risk of stroke in pregnancy and puerperium, the overall incidence of the condition in this population is low. Therefore, there is limited data pertaining to these patients particularly from Asian countries. Our objective was to describe the risk factors and outcomes of 110 pregnancy-related ischemic strokes from 5 Asian countries.

METHODS

Data were collected by retrospective chart review in most cases and prospectively in the rest. Inclusion criteria for this subanalysis were women, pregnant or within 1-month postpartum, presenting to the study center with acute ischemic stroke (arterial or venous) confirmed by neuroimaging. Intracranial hemorrhages other than the ones associated with cerebral venous thrombosis or hemorrhagic infarct were excluded. Risk factors were diagnosed based on already published criteria. Outcomes were measured using modified Rankin score. Statistical analysis was done using Statistical Package for Social Sciences version 19.0.

RESULTS

In all, 110 women with mean age of 27.94 years presented with pregnancy-related ischemic strokes; 58.2% of the strokes occurred postpartum and 49.1% were secondary to cerebral venous thrombosis. Venous strokes were significantly more likely to occur postpartum compared with arterial strokes (P=.01), to have abnormal "hypercoagulable panel result on admission" (P<.001), less likely to have traditional stroke risk factors (P<.001), to have hemorrhagic conversion of stroke (P<.001), and to have lesser stroke severity and better functional outcome at 3 months (P<.001 for each).

CONCLUSION

Cerebral venous thrombosis is a significant contributor to pregnancy-related strokes in Asian women. Both traditional and pregnancy-specific risk factors should be addressed to control ischemic stroke risk in these women.

Huge desmoid tumor of the anterior abdominal wall mimicking an intraabdominal mass in a postpartum woman: a case report

Desmoid tumors are benign neoplasms that most often arise from muscle aponeurosis and have been associated with both trauma and pregnancy. The etiology of desmoids has not been determined. We report the case of anterior abdominal wall desmoid tumor in a female patient with previous history of cesarean section. Preoperative ultrasound and computed tomography demonstrated a large mass mimicking a large hematoma or an intraabdominal mass. The tumor was removed by wide excision with safe margins. The abdominal wall defect was reconstructed with polypropylene mesh. Subsequent histology revealed a desmoid tumor. Desmoid tumors in females are often associated with pregnancy or occur post-partum. The reasons behind this association are unclear. The most common sites are in the abdominal muscles.

A case of postpartum Group B streptococcal meningitis

A case of postpartum Group B streptococcal meningitis, a rare complication of an invasive infection by a common maternal commensal bacterium, which demonstrates the need to develop rapid and accurate antepartum and intrapartum screening methods for this organism.

Spontaneous adrenal hemorrhage during pregnancy: review of literature and case report of successful conservative management

Spontaneous adrenal hemorrhage is an acute hemorrhage from the adrenal gland which occurs in the absence of trauma. The incidence of this condition during pregnancy is unknown. We describe a patient with massive unilateral adrenal hemorrhage which occurred during labor. The patient was successfully managed conservatively with complete resolution of the hematoma. A review of the literature of this rare condition is also presented.

Pregnancy reduces brain sigma receptor function

1. Sigma (sigma) receptors have recently been cloned, though their endogenous ligand(s) remain unidentified. However, some neuroactive steroids, such as progesterone, have a high affinity for these receptors. Some sigma ligands, such as DTG, (+)-pentazocine and DHEA, act as sigma 'agonists' by potentiating the neuronal response to NMDA. Others, such as haloperidol, NE-100 and progesterone, act as sigma 'antagonists' by reversing the potentiations induced by sigma 'agonists'. 2. We compared the effects of sigma 'agonists' in four series of female rats: in controls, at day 18 of pregnancy, at day 5 post-partum, and in ovariectomized rats following a 3-week treatment with a high dose of progesterone. 3. In pregnant rats and following a 3-week treatment with progesterone, 10 fold higher doses of DTG, (+)-pentazocine and DHEA were required to elicit a selective potentiation of the NMDA response comparable to that obtained in control females. Conversely, at day 5 post-partum and following the 3-week treatment with a progesterone and after a 5-day washout, the potentiation of the NMDA response induced by the sigma 'agonist' DTG was greater than in control females. 4. The present data suggest that endogenous progesterone acts as an 'antagonist' at sigma receptors. The resulting changes in the function of sigma receptors during pregnancy and post-partum may be implicated in emotional phenomena occurring during these periods.

A long-term study on the health status and performance of sows on different feed allowances during late pregnancy. III. Escherichia coli and other bacteria, total cell content, polymorphonuclear leucocytes and pH in colostrum and milk during the first 3 weeks of lactation

The objectives of this study were to (1) estimate the clinical status of the mammary glands and (2) compare it with the bacteriological findings, the total cell content (TCC) and its percentage of polymorphonuclear leucocytes (PMNLs) and pH in colostrum and milk secretion of sows on 2 different feeding regimes, high versus low, during late pregnancy. The milk samples were collected from both agalactia post partum (APP) sows and clinically healthy sows. Sows with a rectal temperature exceeding 39.5 degrees C within 48 h after parturition were considered to be diseased in APP and treated medically. The sows were sampled on days 1, 3, 8 and 22 of lactation during 6 consecutive lactations. Irrespective of feeding regimes, 49 out of 77 lactations among the APP sows and 15 out of 96 lactations among the clinically healthy sows revealed E. coli in pure cultures with a concomitant TCC exceeding 10 x 10(6) cell/ml already on the first day of lactation. The healthy sows with E. coli infection were denominated as being subclinically infected sows. The intensity in growth of E. coli successively declined, and the bacteria were finally eliminated between days 3 and 8 of lactation. The TCC were 82 x 10(6) cells/ml and 157 x 10(6) cells/ml in the clinically and subclinically E. coli infected glands, respectively, on the first day of sampling. The TCC declined gradually in both groups of sows, but was still higher than in bacteriologically negative milk on day 22 of lactation. The percentages of PMNLs were 66% and 79% in clinically and subclinically infected glands, respectively, on day 1 of lactation, thereafter decreasing to approximately 50% on day 22 of lactation in both groups of sows. In APP sows, swelling, reddening and/or soreness were registered in 38 out of 87 mammary glands with E. coli mastitis on the first sampling occasion. The TCC in bacteriologically negative colostrum and milk collected from APP sows on day 1 of lactation was significantly higher, 2.27 x 10(6) cells/ml, when compared with the TCC in bacteriologically negative milk secretion from the clinically healthy or subclinically infected sows, 1.38 x 10(6) cells/ml versus 1.51 x 10(6) cells/ml, respectively. The PMNLs were higher on day 1 in clinically healthy sows, 59.6%, than in subclinically infected and APP sows (43.5% and 48.3% respectively). The pH in secretion from clinically or subclinically E. coli infected glands (6.57 versus 6.46) were higher than in bacteriologically negative colostrum samples (6.29) from clinically diseased sows on the first day of sampling. On day 22 of lactation, pH-values had stabilized on a level of approximately 7.00 in all milk samples from earlier bacteriologically positive or negative mammary glands. The 2 feeding regimes, low versus high, were not found to influence TCC, PMNLs or pH except for TCC in bacteriologically negative samples of APP sows (2.69 versus 3.62). The lactation number influenced the PMNLs in both groups of sows with E. coli infected mammary glands, and both the TCC and PMNLs in bacteriologically negative colostrum and milk.

A long-term study on the health status and performance of sows on different feed allowances during late pregnancy. II. The total cell content and its percentage of polymorphonuclear leucocytes in pathogen-free colostrum and milk collected from clinically healthy sows

The main objective of this study was to determine the total cell content, TCC, and the percentage of polymorphonuclear leucocytes, PMNLs, in colostrum and milk collected from sows during the first 22 days of lactation. The pH-values during the same sampling period were also determined. It should be emphasized that all the values obtained emanate from bacteriologically negative colostrum and milk. The potential influence of different levels of late gestation feeding regimes was also evaluated. The TCC-values obtained from milk samples during the first 3 weeks of lactation and exceeding the designated threshold of 10 x 10(6) cells/ml varied between 4% and 21%. Within the TCC-limitation of 10-19.99 x 10(6) cells/ml neither the preceding nor the succeeding cell counts exceeded the threshold in 26.8%. TCC-values above 19.99 x 10(6) cells/ml were preceded and succeeded by cell counts below the threshold in 58.8% and 58.8%, respectively. The TCC-levels below the threshold of 10 x 10(6) cells/ml, expressed as geometric least square means, increased significantly from day 1 to day 3 (1.23 x 10(6) cells/ml versus 1.86 x 10(6) cells/ml) and decreased thereafter gradually to day 22 (1.38 x 10(6) cells/ml). When all values were included, the TCC-values increased in a similar pattern from day 1 to day 3 (1.38 x 10(6) cells/ml versus 3.18 x 10(6) cells/ml). The value on day 22 of lactation was still on a significantly elevated level compared with that of day 1 (2.10 x 10(6) cells/ml versus 1.38 x 10(6) cells/ml). The 2 different feeding regimes were not found to influence the TCC-values during the first 22 days of lactation. In the whole material the PMNL-values, expressed as percentages of the TCC, declined from approximately 60% on day 1 of lactation to between 40% and 50% for the remaining sampling period. This decline was comparable with the one seen in the cell class below the threshold of 10 x 10(6) cells/ml. In the 2 cell classes above 9.99 x 10(6) cells/ml, 78.0% and 88.8% of PMNLs on day 1 declined to about 40% on day 22. This might indicate an inflammatory response on day 1 but without any detectable bacteriological growth. The increase in lactation number, if lactation 1 was compared with the following lactations, revealed a significant rise (p < 0.05) in TCC-level and percentage level of PMNLs. A stepwise and significant increase in pH-level occurred between days 1, 3 and 8 (6.18, 6.56, 7.03) followed by a significant decrease to day 22 (6.91) when pH-values from milk of all cell classes were included.

Maternally-derived passive immunity to enterotropic mouse hepatitis virus

Maternally-derived antibody to enterotropic mouse hepatitis virus (MHV) strain Y was transferred to pups by both intrauterine (IgG) and lactogenic (IgA and IgG) routes. Antibody present in the gastric whey of pups suckling immune dams dropped to undetectable levels by weaning age (21 days post partum). MHV-specific IgG was found in the serum of passively immune pups up to 10 weeks of age. Immune dams transferred equal levels of antibody to 3 consecutive litters of pups, without evidence of decline. Immunoblots showed that IgA and IgG in whey and serum were directed against nucleoprotein N and glycoprotein S. MHV-specific IgM was not detected in any sample.