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Neef V, Choorapoikayil S, Hof L, Meybohm P, Zacharowski K. Current concepts in postpartum anemia management. Curr Opin Anaesthesiol 2024; 37:234-238. [PMID: 38390913 PMCID: PMC11062600 DOI: 10.1097/aco.0000000000001338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Postpartum anemia (PPA) is common in women after childbirth and affects about 50-80% of all women worldwide. Iron deficiency (ID) is the main cause for anemia and constitutes a potentially preventable condition with great impact on the mother's physical and mental condition after delivery. In most cases, PPA is associated with antenatal ID and peripartum blood losses. Numerous published studies confirmed the positive effect of PPA diagnosis and treatment. RECENT FINDINGS Iron deficiency as well as iron deficiency anemia (IDA) are common in the postpartum period and represent significant health problems in women of reproductive age. SUMMARY Important movements towards early detection and therapy of postpartum anemia have been observed. However, postpartum anemia management is not implemented on a large scale as many healthcare professionals are not aware of the most recent findings in the field. Diagnosis and therapy of PPA, particularly iron supplementation in ID and IDA, has proven to be highly effective with a tremendous effect on women's wellbeing and outcome.
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Affiliation(s)
- Vanessa Neef
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Germany
| | - Suma Choorapoikayil
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Germany
| | - Lotta Hof
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Germany
| | - Patrick Meybohm
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Kai Zacharowski
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Germany
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2
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Viswanathan R, Little SE, Wilkins-Haug L, Seely EW, Berhie SH. The patient experience of a postpartum readmission for hypertension: a qualitative study. BMC Pregnancy Childbirth 2024; 24:358. [PMID: 38745136 PMCID: PMC11094995 DOI: 10.1186/s12884-024-06564-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 05/03/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are the most common cause of postpartum readmission. Prior research led to clinical guidelines for postpartum management; however, the patient experience is often missing from this work. The objective of this study is to understand the perspective of patients readmitted for postpartum hypertension. METHODS This was a qualitative study with data generated through semi-structured interviews. Patients readmitted with postpartum HDP at an urban academic medical center from February to December 2022 were approached and consented for an interview. The same researcher conducted all interviews and patient recruitment continued until thematic saturation was reached (n = 9). Two coders coded all interviews using Nvivo software with both deductive and inductive coding processes. Discrepancies were discussed and resolved with consensus among the two coders. Themes were identified through an initial a priori template of codes which were expanded upon using grounded theory, and researchers were reflexive in their thematic generation. RESULTS Six themes were generated: every pregnancy is different, symptoms of preeclampsia are easily dismissed or minimized by both patient and providers, miscommunication regarding medical changes can increase the risk of readmissions, postpartum care coordination and readmission logistics at our hospital could be improved to facilitate caring for a newborn, postpartum care is often considered separately from the rest of pregnancy, and patient well-being improved when conversations acknowledged the struggles of readmission. CONCLUSIONS This qualitative research study revealed patient-identified gaps in care that may have led to readmission for hypertensive disorders of pregnancy. The specific recommendations that emerge from these themes include addressing barriers to blood pressure management prior to discharge, improving postpartum discharge follow-up, providing newborn care coordination, and improving counseling on the risk of postpartum preeclampsia during discharge. Incorporating these patient perspectives in hospital discharge policy can be helpful in creating patient-centered systems of care and may help reduce rates of readmission.
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Affiliation(s)
- Radhika Viswanathan
- SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA.
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Hospital, New York, NY, USA.
| | - Sarah E Little
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Louise Wilkins-Haug
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ellen W Seely
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Saba H Berhie
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
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3
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Katende A, Roos L, Urio VZ, Mahundi E, Myovela V, Mnzava D, Mlula C, Chitimbwa C, Raphael DM, Gingo W, Franzeck FC, Paris DH, Elzi L, Weisser M, Rohacek M. Recovery of left ventricular systolic function in peripartum cardiomyopathy: an observational study from rural Tanzania. BMC Cardiovasc Disord 2024; 24:243. [PMID: 38724901 PMCID: PMC11080156 DOI: 10.1186/s12872-024-03906-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND The aim of this study was to evaluate the recovery rate of the left ventricular systolic function of women diagnosed with peripartum cardiomyopathy receiving specialized care in rural Tanzania. METHODS In this observational study, women diagnosed with peripartum cardiomyopathy at a referral center in rural Tanzania between December 2015 and September 2021 were included. Women diagnosed between February and September 2021 were followed prospectively, those diagnosed between December 2015 and January 2021 were tracked back for a follow-up echocardiography. All participants received a clinical examination, a comprehensive echocardiogram, and a prescription of guideline-directed medical therapy. The primary outcome was recovery of the left ventricular systolic function (left ventricular ejection fraction > 50%). RESULTS Median age of the 110 participants was 28.5 years (range 17-45). At enrolment, 49 (45%) participants were already on cardiac medication, 50 (45%) had severe eccentric hypertrophy of the left ventricle, and the median left ventricular ejection fraction was 30% (range 15-46). After a median follow-up of 8.98 months (IQR 5.72-29.37), 61 (55%) participants were still on cardiac medication. Full recovery of the left ventricular systolic function was diagnosed in 76 (69%, 95% CI 59.6-77.6%) participants. In the multivariate analysis, a higher left ventricular ejection fraction at baseline was positively associated with full recovery (each 5% increase; OR 1.7, 95% CI 1.10-2.62, p = 0.012), while higher age was inversely associated (each 10 years increase; OR 0.40, 95% CI 0.19-0.82, p = 0.012). CONCLUSION Left ventricular systolic function recovered completely in 69% of study participants with peripartum cardiomyopathy from rural Tanzania under specialized care.
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Affiliation(s)
- Andrew Katende
- St. Francis Regional Referral Hospital, Ifakara, United Republic of Tanzania
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Laurine Roos
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Victor Z Urio
- St. Francis Regional Referral Hospital, Ifakara, United Republic of Tanzania
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Evance Mahundi
- St. Francis Regional Referral Hospital, Ifakara, United Republic of Tanzania
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Victor Myovela
- St. Francis Regional Referral Hospital, Ifakara, United Republic of Tanzania
| | - Dorcas Mnzava
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Chipegwa Mlula
- St. Francis Regional Referral Hospital, Ifakara, United Republic of Tanzania
| | | | - Dominick M Raphael
- St. Francis Regional Referral Hospital, Ifakara, United Republic of Tanzania
| | - Winfrid Gingo
- St. Francis Regional Referral Hospital, Ifakara, United Republic of Tanzania
| | - Fabian C Franzeck
- University of Basel, Basel, Switzerland
- Research and analytics services, University Hospital Basel, Basel, Switzerland
| | - Daniel H Paris
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Luigia Elzi
- Regional Hospital of Bellinzona e Valli, Bellinzona, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Martin Rohacek
- St. Francis Regional Referral Hospital, Ifakara, United Republic of Tanzania.
- Ifakara Health Institute, Ifakara, United Republic of Tanzania.
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
- University of Basel, Basel, Switzerland.
- Swiss Tropical and Public Health Institute (Swiss TPH), Kreuzstrasse 2, Allschwil, 4123, Switzerland.
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Qureshi N, Kontorovich A, Veledar E, Tlachi P, Feltovich H, Mancini DM, Barghash M, Stone J, Bianco A, Shaw LJ, Lala A. Frequency and Clinical Implications of Referrals to Heart Failure Among Patients with Peripartum Cardiomyopathy. J Card Fail 2024; 30:717-721. [PMID: 38158153 DOI: 10.1016/j.cardfail.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/10/2023] [Accepted: 12/05/2023] [Indexed: 01/03/2024]
Abstract
Peripartum cardiomyopathy (PPCM) is a rare but significant cause of new-onset heart failure (HF) during the peri- and post-partum periods. Advances in GDMT for HF with reduced ventricular function have led to substantial improvements in survival and quality of life, yet few studies examine the longitudinal care received by patients with PPCM. The aim of this research is to address this gap by retrospectively characterizing patients with PPCM across a multihospital health system and investigating the frequency of cardiology and HF specialty referrals. Understanding whether surveillance and medical management differ among patients referred to HF will help to underscore the importance of referring patients with PPCM to HF specialists for optimal care.
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Affiliation(s)
- Natasha Qureshi
- Department of Medicine, Mount Sinai Beth Israel, New York, New York
| | - Amy Kontorovich
- Department of Medicine, Division of Cardiology, Cardiovascular Research Institute, Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emir Veledar
- Department of Biostatistics at Robert Stempel College of Public Health Florida International University, Miami, Florida; Department of Cardiology, Emory University, School of Medicine, Atlanta, Georgia
| | - Pilar Tlachi
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Helen Feltovich
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Donna M Mancini
- Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Maya Barghash
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joanne Stone
- The Raquel and Jaime Gilinski Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Angela Bianco
- The Raquel and Jaime Gilinski Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leslee J Shaw
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
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5
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Gao Q, Jiang H, Jia M, Xiong J. Acute puerperal uterine inversion with successful manual transvaginal repositioning: A case report. Medicine (Baltimore) 2024; 103:e37986. [PMID: 38669392 PMCID: PMC11049735 DOI: 10.1097/md.0000000000037986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
RATIONALE Uterine inversion is a rare medical condition that is categorized as puerperal and nonpuerperal. Repositioning of uterine involution can be done manually or surgically, the latter of which involves abdominal manipulation and disruption of the integrity of the uterine wall, which can lead to complications for the patient in subsequent pregnancies, such as uterine rupture. PATIENT CONCERNS We report a case of acute puerperal uterine inversion that was manually repositioned transvaginally. An ultrasonogram and reset schematic were also presented. A 23-year-old woman (gravida 1 para 0) was admitted to the hospital with a full-term pregnancy. DIAGNOSES In the postpartum period, we found placental adhesions and uterine inversion into the uterine cavity, which was confirmed by bedside ultrasound. INTERVENTIONS AND OUTCOMES We administered analgesic, relieving uterine spasms, and antishock therapy along with manual stripping of the placenta and ultrasound-guided uterine repositioning. After successful repositioning the patient vaginal bleeding decreased rapidly and she was discharged 3 days after delivery. LESSONS Early recognition, antishock therapy and prompt repositioning are key in the management of puerperal uterine inversion. We hope that this case will enable clinicians to better visualize the ultrasound imaging of uterine inversion and the process of manual repositioning.
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Affiliation(s)
- Qianqian Gao
- Departments of Obstetrics, Weifang People’s Hospital, First Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China
| | - Hong Jiang
- Departments of Obstetrics, Weifang People’s Hospital, First Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China
| | - Mengmeng Jia
- Departments of Obstetrics, Weifang People’s Hospital, First Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China
| | - Jinqiu Xiong
- Departments of General Surgery, Weifang People’s Hospital, First Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China
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Elendu C, Okoye OK. Peripartum cardiomyopathy: A case report of decompensated heart failure in a hypertensive patient. Medicine (Baltimore) 2024; 103:e37600. [PMID: 38552076 PMCID: PMC10977545 DOI: 10.1097/md.0000000000037600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/23/2024] [Indexed: 04/02/2024] Open
Abstract
RATIONALE Peripartum cardiomyopathy (PPCM) occurring in the context of hypertension presents a unique clinical challenge. This case contributes to the medical literature by highlighting the complexities of managing heart failure in postpartum women with pre-existing hypertensive disorders, particularly when complicated by a history of preeclampsia. PATIENT CONCERNS Mrs. O.O., a 34-year-old hypertensive woman, presented with progressive dyspnea, bilateral leg swelling, and orthopnea. Notably, she had a history of previous preeclampsia and exhibited worsening symptoms over several months. DIAGNOSES The patient was diagnosed with decompensated heart failure secondary to PPCM, exacerbated by hypertension and anemia. INTERVENTIONS Therapeutic interventions included diuretics, angiotensin receptor-neprilysin inhibitors, digoxin, and anticoagulation. Additionally, lifestyle modifications and dietary restrictions were implemented. OUTCOMES Following treatment adjustments, the patient demonstrated significant improvement in symptoms, exercise tolerance, and cardiac function. The transition from NYHA class III to class II heart failure indicated successful management. LESSONS This case underscores the importance of a comprehensive approach to managing PPCM in hypertensive patients, with attention to cardiovascular and obstetric factors. It highlights the effectiveness of multidisciplinary care in achieving positive outcomes and emphasizes the need for heightened vigilance in postpartum women with cardiovascular risk factors.
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Affiliation(s)
- Chukwuka Elendu
- Department of Internal medicine, University of California, Santa Cruz, CA
| | - Osinachi K. Okoye
- Department of Internal medicine, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Awka, Nigeria
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7
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Ejim EC, Karaye KM, Antia S, Isiguzo GC, Njoku PO. Peripartum cardiomyopathy in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 93:102476. [PMID: 38395024 DOI: 10.1016/j.bpobgyn.2024.102476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Peripartum cardiomyopathy (PPCM) causes pregnancy-associated heart failure, typically during the last month of pregnancy, and up to 6 months post-partum, in women without known cardiovascular disease. PPCM is a global disease, but with a significant geographical variability within and between countries. Its true incidence in Africa is still unknown because of the lack of a PPCM population-based study. The variability in the epidemiology of PPCM between and within countries could be due to differences in the prevalence of both genetic and non-genetic risk factors. Several risk factors have been implicated in the aetiopathogenesis of PPCM over the years. Majority of patients with PPCM present with symptoms and signs of congestive cardiac failure. Diagnostic work up in PPCM is prompted by strong clinical suspicion, but Echocardiography is the main imaging technique for diagnosis. The management of PPCM involves multiple disciplines - cardiologists, anaesthetists, intensivists, obstetricians, neonatologists, and the prognosis varies widely.
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Affiliation(s)
- Emmanuel C Ejim
- Department of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu, Nigeria.
| | - Kamilu M Karaye
- Bayero University & Aminu Kano Teaching Hospital Kano, Nigeria.
| | - Samuel Antia
- Department of Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria.
| | - Godsent C Isiguzo
- Department of Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria.
| | - Paschal O Njoku
- Department of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.
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Barreto TW. Management of Postpartum Hypertensive Disorders of Pregnancy. Am Fam Physician 2024; 109:Online. [PMID: 38393804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Affiliation(s)
- Tyler W Barreto
- Family Health Associates, Family Care Network, Bellingham, Washington
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9
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Azad H, Wen T, Bello NA, Booker WA, Purisch S, D'Alton ME, Friedman AM. Peripartum cardiomyopathy delivery hospitalization and postpartum readmission trends, risk factors, and outcomes. Pregnancy Hypertens 2023; 34:116-123. [PMID: 37948872 DOI: 10.1016/j.preghy.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To evaluate risk for peripartum cardiomyopathy during delivery and postpartum hospitalizations, and analyze associated trends, risk factors, and clinical outcomes. METHODS The 2010-2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations along with postpartum readmissions occurring within five months of delivery discharge were analyzed. Risk factors associated with peripartum cardiomyopathy were analyzed with unadjusted and adjusted logistic regression models with odds ratios as measures of effect. Risk for severe adverse outcomes associated with peripartum cardiomyopathy was analyzed. Trends were analyzed with joinpoint regression. RESULTS Of 39,790,772 delivery hospitalizations identified, 9,210 were complicated by a diagnosis of peripartum cardiomyopathy (2.3 per 10,000). Risk for a 5-month readmission with a peripartum cardiomyopathy diagnosis was 4.8 per 10,000. Factors associated with peripartum cardiomyopathy during deliveries included preeclampsia with severe features (OR 18.9, 95 % CI 17.2, 20.7), preeclampsia without severe features (OR 6.9, 95 % CI 6.1, 7.8), multiple gestation (OR 4.7, 95 % CI 4.1, 5.3), chronic hypertension (OR 10.1, 95 % CI 8.9, 11.3), and older maternal age. Associations were attenuated but retained significance in adjusted models. Similar estimates were found when evaluating associations with postpartum readmissions. Peripartum cardiomyopathy readmissions were associated with 10 % of overall postpartum deaths, 21 % of cardiac arrest/ventricular fibrillation diagnoses, 18 % of extracorporeal membrane oxygenation cases, and 40 % of cardiogenic shock. In joinpoint analysis, peripartum cardiomyopathy increased significantly during delivery hospitalizations (average annual percent change [AAPC] 2.2 %, 95 % CI 1.0 %, 3.4 %) but not postpartum readmissions (AAPC 0.0 %, 95 % CI -1.6 %, 1.6 %). CONCLUSION Risk for peripartum cardiomyopathy increased during delivery hospitalizations over the study period. Obstetric conditions such as preeclampsia and chronic medical conditions that are increasing in prevalence in the obstetric population were associated with the highest odds of peripartum cardiomyopathy.
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Affiliation(s)
- Hooman Azad
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Timothy Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California-San Francisco, San Francisco, CA, USA
| | - Natalie A Bello
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Stephanie Purisch
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA.
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10
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Rosenfeld EB, Brandt JS, Fields JC, Lee R, Graham HL, Sharma R, Ananth CV. Chronic Hypertension and the Risk of Readmission for Postpartum Cardiovascular Complications. Obstet Gynecol 2023; 142:1431-1439. [PMID: 37917949 PMCID: PMC10662390 DOI: 10.1097/aog.0000000000005424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Preeclampsia is an important risk factor for cardiovascular disease (CVD, including heart disease and stroke) along the life course. However, whether exposure to chronic hypertension in pregnancy, in the absence of preeclampsia, is implicated in CVD risk during the immediate postpartum period remains poorly understood. Our objective was to estimate the risk of readmission for CVD complications within the calendar year after delivery for people with chronic hypertension. METHODS The Healthcare Cost and Utilization Project's Nationwide Readmission Database (2010-2018) was used to conduct a retrospective cohort study of patients aged 15-54 years. International Classification of Diseases codes were used to identify patients with chronic hypertension and postpartum readmission for CVD complications within 1 year of delivery. People with CVD diagnosed during pregnancy or delivery admission, multiple births, or preeclampsia or eclampsia were excluded. Excess rates of CVD readmission among patients with and without chronic hypertension were estimated. Associations between chronic hypertension and CVD complications were determined from Cox proportional hazards regression models. RESULTS Of 27,395,346 delivery hospitalizations that resulted in singleton births, 2.0% of individuals had chronic hypertension (n=544,639). The CVD hospitalization rate among patients with chronic hypertension and normotensive patients was 645 (n=3,791) per 100,000 delivery hospitalizations and 136 (n=37,664) per 100,000 delivery hospitalizations, respectively (rate difference 508, 95% CI 467-549; adjusted hazard ratio 4.11, 95% CI 3.64-4.66). The risk of CVD readmission, in relation to chronic hypertension, persisted for 1 year after delivery. CONCLUSION The heightened CVD risk as early as 1 month postpartum in relation to chronic hypertension underscores the need for close monitoring and timely care after delivery to reduce blood pressure and related complications.
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Affiliation(s)
- Emily B. Rosenfeld
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Justin S. Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, New York University Langone, New York, NY
| | - Jessica C. Fields
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Rachel Lee
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Hillary L. Graham
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Clinical Epidemiology Division, Faculty of Medicine at Solna, Karolinska Institute, Stockholm, Sweden
| | - Ruchira Sharma
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Cande V. Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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11
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Bala R, Mehta S, Roy VC, Kaur G, de Marvao A. Peripartum cardiomyopathy: A review. Rev Port Cardiol 2023; 42:917-924. [PMID: 37414337 DOI: 10.1016/j.repc.2023.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/07/2023] [Indexed: 07/08/2023] Open
Abstract
Peripartum cardiomyopathy is a rare type of heart failure manifesting towards the end of pregnancy or in the months following delivery, in the absence of any other cause of heart failure. There is a wide range of incidence across countries reflecting different population demographics, uncertainty over definitions and under-reporting. Race, ethnicity, multiparity and advanced maternal age are considered important risk factors for the disease. Its etiopathogenesis is incompletely understood and is likely multifactorial, including hemodynamic stresses of pregnancy, vasculo-hormonal factors, inflammation, immunology and genetics. Affected women present with heart failure secondary to reduced left ventricular systolic function (LVEF <45%) and often with associated phenotypes such as LV dilatation, biatrial dilatation, reduced systolic function, impaired diastolic function, and increased pulmonary pressure. Electrocardiography, echocardiography, magnetic resonance imaging, endomyocardial biopsy, and certain blood biomarkers aid in diagnosis and management. Treatment for peripartum cardiomyopathy depends on the stage of pregnancy or postpartum, disease severity and whether the woman is breastfeeding. It includes standard pharmacological therapies for heart failure, within the safety restrictions for pregnancy and lactation. Targeted therapies such as bromocriptine have shown promise in early, small studies, with large definitive trials currently underway. Failure of medical interventions may require mechanical support and transplantation in severe cases. Peripartum cardiomyopathy carries a high mortality rate of up to 10% and a high risk of relapse in subsequent pregnancies, but over half of women present normalization of LV function within a year of diagnosis.
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Affiliation(s)
- Rajni Bala
- Department of Biotechnology, Punjabi University, Patiala, India; Adduct Healthcare Pvt. Ltd., Mohali, India
| | - Sakshi Mehta
- Adduct Healthcare Pvt. Ltd., Mohali, India; Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Vikas C Roy
- Department of Pharmacy, Global College of Pharmacy, Kahanpur, Punjab, India
| | - Geetika Kaur
- Integrative Biosciences Center, Wayne State University, Detroit, MI 48202, USA; Department of Ophthalmology, Visual and Anatomical Sciences, School of Medicine, Wayne State University, Detroit, MI 48202, USA
| | - Antonio de Marvao
- Department of Women and Children's Health, King's College London, London, United Kingdom; British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
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12
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Matemvu Z, Likapa H, Makin MS, Hossain O. Five cases of Peripartum Cardiomyopathy in Malawi. Malawi Med J 2023; 35:196-200. [PMID: 38362291 PMCID: PMC10865061 DOI: 10.4314/mmj.v35i3.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Aim This report of five cases of peripartum cardiomyopathy (PPCM) treated at Daeyang Luke Hospital in Lilongwe, Malawi, illustrates presentation and treatment of this increasingly commonly recognized medical condition. Methods Information including history, physical examination, and imaging studies were collected from five cases of peripartum women who presented to the hospital over an 18-month period. Results A summary of recommended treatment is included in table form, and a flow chart proposing a care pathway for managing PPCM in Malawi, beginning at the district hospital level, is presented. Conclusion Clinical recognition, appropriate diagnostic modalities, and informed treatment of PPCM in Malawi will improve care of peripartum woman and reduce maternal morbidity and mortality.
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Affiliation(s)
- Zaithwa Matemvu
- Lilongwe Central Hospital, Ministry of Health, Lilongwe, Malawi
| | | | - Mary Sue Makin
- Daeyang Luke Hospital, Lilongwe, Malawi
- Ekwendeni College of Health Sciences, Malawi
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13
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Lovell JP, Bermea K, Yu J, Rousseau S, Cohen CD, Bhalodia A, Zita MD, Head RD, Blumenthal RS, Alharethi R, Damp J, Boehmer J, Alexis J, McNamara DM, Sharma G, Adamo L. Serum Proteomic Analysis of Peripartum Cardiomyopathy Reveals Distinctive Dysregulation of Inflammatory and Cholesterol Metabolism Pathways. JACC Heart Fail 2023; 11:1231-1242. [PMID: 37542511 DOI: 10.1016/j.jchf.2023.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND The pathophysiology of peripartum cardiomyopathy (PPCM) and its distinctive biological features remain incompletely understood. High-throughput serum proteomic profiling, a powerful tool to gain insights into the pathophysiology of diseases at a systems biology level, has never been used to investigate PPCM relative to nonischemic cardiomyopathy. OBJECTIVES The aim of this study was to characterize the pathophysiology of PPCM through serum proteomic analysis. METHODS Aptamer-based proteomic analysis (SomaScan 7K) was performed on serum samples from women with PPCM (n = 67), women with nonischemic nonperipartum cardiomyopathy (NPCM) (n = 31), and age-matched healthy peripartum and nonperipartum women (n = 10 each). Serum samples were obtained from the IPAC (Investigation of Pregnancy-Associated Cardiomyopathy) and IMAC2 (Intervention in Myocarditis and Acute Cardiomyopathy) studies. RESULTS Principal component analysis revealed unique clustering of each patient group (P for difference <0.001). Biological pathway analyses of differentially measured proteins in PPCM relative to NPCM, before and after normalization to pertinent healthy controls, highlighted specific dysregulation of inflammatory pathways in PPCM, including the upregulation of the cholesterol metabolism-related anti-inflammatory pathway liver-X receptor/retinoid-X receptor (LXR/RXR) (P < 0.01, Z-score 1.9-2.1). Cardiac recovery by 12 months in PPCM was associated with the downregulation of pro-inflammatory pathways and the upregulation of LXR/RXR, and an additional RXR-dependent pathway involved in the regulation of inflammation and metabolism, peroxisome proliferator-activated receptor α/RXRα signaling. CONCLUSIONS Serum proteomic profiling of PPCM relative to NPCM and healthy controls indicated that PPCM is a distinct disease entity characterized by the unique dysregulation of inflammation-related pathways and cholesterol metabolism-related anti-inflammatory pathways. These findings provide insight into the pathophysiology of PPCM and point to novel potential therapeutic targets.
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Affiliation(s)
- Jana P Lovell
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin Bermea
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jinsheng Yu
- Department of Genetics, McDonnell Genome Institute, Washington University, St. Louis, Missouri, USA
| | - Sylvie Rousseau
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles D Cohen
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aashik Bhalodia
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcelle Dina Zita
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard D Head
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Roger S Blumenthal
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Julie Damp
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John Boehmer
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jeffrey Alexis
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Dennis M McNamara
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. https://twitter.com/GarimaVSharmaMD
| | - Luigi Adamo
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Yaniv-Salem S, Dym L, Nesher L, Zahger D, Shalev A, Shmueli H. Post-COVID-19 Peripartum Cardiomyopathy: Experience from a Large Tertiary Referral Center. Isr Med Assoc J 2023; 25:533-537. [PMID: 37574890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) is a rare but potentially devastating complication of pregnancy. Although the pathophysiology of PPCM is not fully understood, there are known risk factors for developing PPCM, which are maternal and gestation related. In the first wave of the coronavirus disease 2019 (COVID-19) pandemic, we witnessed an elevated incidence of PPCM among COVID-19 survivors. OBJECTIVES To present a single-center case series of three patients diagnosed with peripartum cardiomyopathy after recovered from COVID-19 during the index pregnancy. METHODS In this single center case study, all patients diagnosed with PPCM at our institute during the examined time frame were included. Electronic medical records were studied. RESULTS Three patients previously diagnosed with asymptomatic or mildly symptomatic COVID-19 disease during pregnancy presented with PPCM before or shortly after delivery. Patients underwent testing to rule out residual COVID-19 myocarditis, were treated pharmacologically and with wearable defibrillators as needed, and were examined in follow-up 1-9 months after delivery. CONCLUSIONS Residual endothelial damage due to COVID-19 disease, even if originally mild in presentation, could predispose pregnant patients to PPCM and should be considered as a risk factor when assessing patients with new onset symptoms of heart failure. Further research is needed to confirm this hypothesis and fully determine the underlying pathophysiology. These preliminary findings warrant a high index of suspicion for PPCM in COVID-19 recoverers.
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Affiliation(s)
- Shimrit Yaniv-Salem
- Department of Gynecology and Obstetrics, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Lianne Dym
- Department of Gynecology and Obstetrics, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Lior Nesher
- Department of Infectious Diseases, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Aryeh Shalev
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Hezzy Shmueli
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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15
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Eerdekens GJ, Devroe S, Budts W, Rex S. Anesthetic management of patients with peripartum cardiomyopathy. Curr Opin Anaesthesiol 2023; 36:269-275. [PMID: 36794897 DOI: 10.1097/aco.0000000000001244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease is increasingly emerging as a cause of peripartum morbidity and mortality. Peripartum cardiomyopathy (PPCM) is defined as pregnancy-related heart failure with a reduced left ventricular ejection fraction <45%. PPCM develops in the peripartum phase and is not an aggravation of an existing prepregnancy cardiomyopathy. Anesthesiologists typically encounter these patients in the peripartum phase in a variety of settings and should be aware of this pathology and its implications for the perioperative management of parturients. RECENT FINDINGS PPCM has been investigated increasingly over the last few years. Significant progress has been made in the assessment of global epidemiology, pathophysiological mechanisms, genetics and treatment. SUMMARY Although PPCM is an overall rare pathology, patients can potentially be encountered by any anesthesiologist in many different settings. Therefore, it is important to be aware of this disease and understand the basic implications for anesthetic management. Severe cases often require early referral to specialized centers for advanced hemodynamic monitoring and pharmacological or mechanical circulatory support.
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Affiliation(s)
| | | | - Werner Budts
- Department of Cardiology, University Hospitals Leuven
- Congenital and Structural Cardiology, Division Cardiovascular Diseases
| | - Steffen Rex
- Department of Anesthesiology
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
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16
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Prickett MA, Howell CM. A patient with untreated preeclampsia and peripartum cardiomyopathy. JAAPA 2023; 36:25-27. [PMID: 36815845 DOI: 10.1097/01.jaa.0000911224.29850.f5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
ABSTRACT The pathophysiologic process of peripartum cardiomyopathy, a rare and potentially life-threatening condition, is not completely understood. One theory is a possible link between the development of preeclampsia and peripartum cardiomyopathy. These two conditions have been linked to significant mortality in peripartum or postpartum patients. Clinicians must be able to identify the two, their differences, and start appropriate therapies immediately.
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Affiliation(s)
- Mara A Prickett
- Mara A. Prickett is principal faculty in the PA program at Mount St. Joseph University and practices in emergency medicine at Qualified Emergency Specialists Inc., both in Cincinnati, Ohio. Christopher M. Howell is an associate clinical professor and program director at Miami University in Oxford, Ohio, and practices in emergency, family, and addiction medicine in Ohio and Indiana. The authors have disclosed no potential conflicts of interest, financial or otherwise
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17
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Yuzuk N, Bove J, Desai R. Managing Postpartum Complications in the Emergency Department. Emerg Med Pract 2022; 24:1-24. [PMID: 35195979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/10/2021] [Indexed: 06/14/2023]
Abstract
Postpartum patients may present to the emergency department with complaints ranging from minor issues, requiring only patient education and reassurance, to severe, life-threatening complications that require prompt diagnosis and multidisciplinary consultation and management. At times, vague presentations or overlapping conditions can make it difficult for the emergency clinician to recognize an emergent condition and initiate proper treatment. This issue reviews the major common emergencies that present in postpartum patients, by chief complaint, including hemorrhage, infection, pre-eclampsia, eclampsia, headache, and cardiopulmonary conditions, and reviews the most recent evidence and guidelines.
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Affiliation(s)
- Nicole Yuzuk
- Ultrasound Director, Core Faculty, St. Joseph's University Medical Center, Paterson, NJ
| | - Joseph Bove
- Emergency Physician, St. Joseph's University Medical Center, Paterson, NJ
| | - Riddhi Desai
- Department of Emergency Medicine, St. Joseph's University Medical Center, Paterson, NJ
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18
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Tseng JY, Lin IC, Lin JH, Chang CM, Chao WT, Wang PH. Optimal approach for management of postpartum vulva hematoma: Report of three cases. Taiwan J Obstet Gynecol 2021; 59:780-783. [PMID: 32917338 DOI: 10.1016/j.tjog.2020.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Vulvar hematomas though common in obstetrical practice can rapidly evolve into a life-threatening condition if not managed appropriately. Depending on clinical status and medical facility, conservative management, surgical debridement, or vessel-occlusion strategy can be considered. CASE REPORT Case 1 was a 28 year-old pregnant woman. Increasing hematoma over 12 cm in size was noted on postpartum Day 2. Debridement and arterial embolization were done. Case 2 was a referred woman at age of 30 who delivered at a local obstetric clinic. Debridement was performed successfully. Case 3 was a 23 year-old woman with postpartum bilateral hematoma. Drop in hemoglobin level prompted the medical team to transfer and airlift the patient for arterial embolization and subsequent vulva debridement. CONCLUSION Optimal management of hematoma is dependent on maternal hemodynamic condition, bleeding status, and availability of interventional radiology.
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Affiliation(s)
- Jen-Yu Tseng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - I-Chia Lin
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Jun-Hung Lin
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Chia-Ming Chang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Wei-Ting Chao
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming University, School of Medicine, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan; Female Cancer Foundation, Taipei, Taiwan.
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19
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Bøttcher KSE, Nilsson ME, Vinberg M. [Post-partum psychosis]. Ugeskr Laeger 2021; 183:V01210020. [PMID: 34120688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Post-partum psychosis (PPP) is a severe psychiatric emergency. The condition is rare and has generally not been an area of overwhelming research, and concordantly, early identification and treatment is a challenge. Research in the field suggests, that PPP often is a bipolar spectrum illness, and resent research has identified the most common symptoms. This review is an updated description of the phenotypical characteristics of the illness and treatment recommendations based on the newest research.
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Zheng Y, Yang H, Yin X, Ma X, Guo L. Acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor disorders: A protocol of randomized controlled trial. Medicine (Baltimore) 2021; 100:e25511. [PMID: 34114980 PMCID: PMC8202566 DOI: 10.1097/md.0000000000025511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Female pelvic floor dysfunction is one of the common chronic diseases affecting women's physical and mental health. Pregnancy and delivery are one of the main causes. Pelvic floor rehabilitation is a common method for the treatment of postpartum pelvic floor dysfunction, but it has some defects. Acupoint injection has advantages in the treatment of postpartum pelvic floor dysfunction, but there is a lack of standard clinical research to verify it. Therefore, the purpose of this randomized controlled trial is to evaluate the efficacy and safety of acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor disorders. METHODS This is a prospective randomized controlled trial to study the efficacy and safety of acupoints injection combined with pelvic floor rehabilitation. And it is approved by the Ethics Committee of Clinical Research of our hospital. Patients were randomly divided into observation group (acupoint injection combined with pelvic floor rehabilitation group) or control group (pelvic floor rehabilitation group alone). The patients were followed up for 8 weeks after 12 weeks of treatment. The observation indexes included: pelvic organ prolapse degree, pelvic floor muscle strength, urinary incontinence score, adverse reactions, among others. Data were analyzed using the statistical software package SPSS version 18.0. CONCLUSIONS This study will evaluate the efficacy and safety of acupoint injection combined with pelvic floor rehabilitation in the treatment of postpartum pelvic floor dysfunction, and provide reliable reference for the clinical application of this project. TRIAL REGISTRATION OSF Registration number: DOI 10.17605/OSF.IO/VC65Z.
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Affiliation(s)
| | | | - Xunfu Yin
- College of Artificial Intelligence, Southwest University, Chongqing, China
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21
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Abstract
ABSTRACT Although awareness of postpartum depression (PPD) has increased, postpartum anxiety disorders (PPA) remain overlooked. Understanding women's knowledge of PPA and their effective treatments is needed given the underutilization of treatment and associated negative health outcomes. Two internet-based studies (OSF [https://osf.io/3fjvr] preregistered follow-up) were conducted to identify women's knowledge and familiarity with PPD and PPA and knowledge of cognitive behavioral therapy (CBT). Study 1 revealed that women who were planning to become pregnant, pregnant, or recently postpartum (N = 218) were less familiar with PPA than PPD and had limited familiarity with CBT. Women also reported low screening rates for PPA and low perceived treatment seeking for women with PPA and PPD. Study 2 (N = 290) revealed that recently postpartum women recognized fewer symptoms and recommended treatment less often for PPA than PPD and had limited CBT knowledge. Overall, results indicate limited knowledge of PPA compared with PPD, indicating a need for targeted information to perinatal women.
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22
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Li T, Hui X, Wang H, Lin Y, Zhao B. Moxibustion therapy for treating patients with postpartum urinary retention: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e25683. [PMID: 33907140 PMCID: PMC8084072 DOI: 10.1097/md.0000000000025683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Postpartum urinary retention (PUR) is one of the most common complications after parturition which affect women's recovery after childbirth. Many clinical trials have shown that moxibustion, a traditional Chinese medicine therapy, is effective in treating PUR. But its effectiveness has not been evaluated scientifically and systematically. Therefore, this review aims to evaluate the safety and effectiveness of moxibustion therapy in treating patients with PUR. METHODS We will search the following electronic databases, regardless of publication status and languages, from their respective inception dates to February 2021: the Cochrane Central Register of Controlled Trails, Pubmed, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Chinese Scientific Journal Database, and Wan-Fang Database. Clinical randomized controlled trials (RCTs) related to moxibustion therapy for treating PUR will be included. Study selection, data collection, and quality assessment will be independently conducted by 2 researchers. For data synthesis, we will select either the fixed-effects or random-effects model according to heterogeneity assessment. Cure rates and postvoid residual volume (PVRV) will be the primary outcomes. The total effective rate and first urination time will be the second outcomes. Review Manager Software (RevMan) V.5.3 will be used if it is appropriate for meta-analysis. Otherwise, a systematic narrative synthesis will be conducted. The results will be presented as risk ratio (RR) with 95% confidence interval (CI) for dichotomous data and weight mean difference (WMD) or standard mean difference (SMD) 95% CI for continuous data. TRIAL REGISTRATION NUMBER INPLASY 202140037.
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23
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Abstract
Peripartum cardiomyopathy is now increasingly recognized as a cause of heart failure in the later months of pregnancy and early postpartum period. Clinical diagnosis may be challenging as it closely resembles several common medical and obstetric complications. Complex pathogenesis, unpredictable onset, staggered recovery, and unanticipated fetomaternal risks pose unique challenge to clinicians. Prevalence seems to vary with race, geographic location, and diagnostic criteria. The presence of multiple risk factors substantially elevates the risk of PPCM. Transthoracic echocardiographic examination can exclude the majority of the mimickers. Symptomatic presentation is initially limited to, varying grades of low cardiac output syndrome. Rarely, PPCM begins with decompensated heart failure and cardiovascular collapse. Guideline-directed medical therapy involves graded initiation and titration of heart failure medications while ensuring the fetal and neonatal safety. Anesthetic and obstetric management should be individualized to improve fetomaternal outcomes. However, emergent cesarean delivery may be required in women with decompensated heart failure and cardiovascular collapse. An early institution of mechanical circulatory support has shown to improve outcome. Bromocriptine and other experimental drugs designed to target pathogenic pathway have yielded mixed results. A further change in approach to management requires a comprehensive understanding of pathophysiology and fetomaternal safety profiles of heart failure medications.
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Affiliation(s)
- Nivedita Jha
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Ajay Kumar Jha
- Cardiothoracic Division, Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India.
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Hamm RF, Perelman S, Wang EY, Levine LD, Srinivas SK. Single-unit vs multiple-unit transfusion in hemodynamically stable postpartum anemia: a pragmatic randomized controlled trial. Am J Obstet Gynecol 2021; 224:84.e1-84.e7. [PMID: 32652065 DOI: 10.1016/j.ajog.2020.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/07/2020] [Accepted: 07/07/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND The American Academy of Blood Banks recommends single-unit red cell transfusion protocols across medicine to reduce transfusion complications and the use of a scarce resource. There are minimal data regarding single-unit protocols in obstetrics. OBJECTIVE We aimed to compare single-unit vs multiple-unit transfusion protocols for treatment of hemodynamically stable postpartum anemia. STUDY DESIGN We performed a randomized trial comparing initial transfusion with 1 unit of packed red blood cells (single-unit protocol) to 2 units of packed red blood cells (multiple-unit protocol) from March 2018 to July 2019. Women who required transfusion >6 hours postpartum were approached for consent. Unstable vital signs, hemoglobin level <5 g/dL, hemoglobinopathy, and cardiomyopathy were exclusion criteria for enrollment. Hemoglobin assessment and standardized clinical evaluation were performed 4 to 6 hours posttransfusion; additional packed red blood cells were given if indicated. The primary outcome was total units transfused. Secondary outcomes included length of stay, endometritis, wound separation or infection, venous thromboembolism, and intensive care unit admission within 30 days postpartum. Breastfeeding, depression, maternal attachment, and fatigue scores were assessed at 4 to 9 weeks postpartum. A total of 66 women were required to detect a 20% reduction in units transfused with a single-unit protocol (power=80%; α=0.05). RESULTS A total of 66 women were randomized (33 per arm). There were no differences between groups in demographic or clinical characteristics, including delivery mode, blood loss, and randomization hemoglobin levels. The mean number of units transfused was lower in the single-unit protocol than in the multiple-unit protocol (1.2 U vs 2.1 U; P<.001). Only 18.2% of women in the single-unit arm required additional packed red blood cells. At posttransfusion assessment, women in the single-unit arm had lower hemoglobin levels (7.8 g/dL vs 8.7 g/dL; P<.001), but there were no differences in vital signs or symptoms between groups. There were also no differences in length of stay, 30-day complications, or 4 to 9 week postpartum outcomes. CONCLUSION In women with hemodynamically stable postpartum anemia, a single-unit protocol avoided a second unit of packed red blood cells in >80% of women without significant impact on morbidity. Our work supports the use of single-unit initial transfusion in this population.
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Affiliation(s)
- Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Sarah Perelman
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eileen Y Wang
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sindhu K Srinivas
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Tshilanda M, Kanmounye US, Tendobi C, Mbuyi F. Diagnostic dilemma in postpartum associated hemolytic uremic syndrome in a 38th week pregnant 31-year-old Congolese: a case report. BMC Pregnancy Childbirth 2020; 20:495. [PMID: 32854648 PMCID: PMC7457258 DOI: 10.1186/s12884-020-03185-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy is associated with HELLP syndrome, thrombotic thrombocytopenic purpura, or atypical hemolytic uremic syndrome (aHUS) during pregnancy. Standard laboratory and physical examinations can help distinguish between these three diseases promptly and guide their management. This is critical because their managements and prognoses differ considerably. The ADAMTS13 test, complement tests, and biopsies can help ascertain the diagnosis; however, they take time, and are not widely available. In this case report, we present a case that highlights the diagnostic and therapeutic dilemmas associated with the aforementioned diseases. CASE PRESENTATION A 31-year old P3G3 patient presented at 38 weeks with high blood pressure, bilateral pitting edema, and a low fetal heart rate. A cesarean section was performed to extract the fetus. On postoperative day 2, the suites were marked by anemia, low platelet count, acute kidney injury, declining liver function, and the presence of schistocytes on the peripheral thin smear. The patient was lucid, coherent, and presented no neurological deficits. The ADAMTS13 test and anti-complement therapy were not readily available, so the team made a presumptive diagnosis of aHUS based on the history, clinical presentation, and standard laboratory results. Due to a lack of anticomplement therapy, the patient was prescribed four sessions of hemodialysis. The renal function and platelet count gradually increased, and the patient was discharged on postoperative day 18. The patient was followed for over a year and did not present relapses of thrombocytopenia or microangiopathic hemolytic anemia. CONCLUSIONS The prompt diagnosis and management of aHUS lead to favorable outcomes. Healthcare providers should be able to rapidly differentiate between pregnancy-associated thrombotic microangiopathies and prescribe appropriate management. Here, we highlighted the challenges of diagnosing and managing postpartum associated aHUS in a low-resource setting.
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Affiliation(s)
- Marc Tshilanda
- Department of Obstetrics and Gynecology, Centre Hospitalier Mère-Enfant (CHME) Monkolé, Kinshasa, Democratic Republic of Congo
- Faculty of Medicine, Université Notre-Dame du Kasayi, Kananga, Democratic Republic of Congo
| | - Ulrick Sidney Kanmounye
- Faculty of Medicine, Université Technologique Bel Campus, Kinshasa, Democratic Republic of Congo.
| | - Céline Tendobi
- Department of Obstetrics and Gynecology, Centre Hospitalier Mère-Enfant (CHME) Monkolé, Kinshasa, Democratic Republic of Congo
| | - Freddy Mbuyi
- Department of Obstetrics and Gynecology, Centre Hospitalier Mère-Enfant (CHME) Monkolé, Kinshasa, Democratic Republic of Congo
- Faculty of Medicine, Université de Kinshasa, Kinshasa, Democratic Republic of Congo
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Wang Y, Li H, Wang J, Hao Q, Tu Y, Chen Y, Qiu M, Peng W, Liu Y, Zhu T. A network meta-analysis protocol of conservative interventions for urinary incontinence in postpartum women. Medicine (Baltimore) 2020; 99:e21772. [PMID: 32872075 PMCID: PMC7437778 DOI: 10.1097/md.0000000000021772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Postpartum urinary incontinence (PPUI) is a common urological condition in women after childbirth. Due to the side effects of surgical and pharmacological therapies, the patients and physicians alike express a strong preference for conservative approaches on PPUI, such as pelvic floor muscle training, biofeedback, electrical stimulation, bladder training, vaginal cones and acupuncture. Application of these conservative approaches should be guided by high quality evidence, yet their comparative effectiveness has not been well documented. Therefore, the network meta-analysis aims to compare, rank and summarize all available studies to determine which conservative intervention is more effective for PPUI. METHODS In this present study, qualified English and Chinese studies will be searched in PubMed, Scopus, EMBASE, The Cochrane Library, Web of Science, VIP Database, Wanfang Database, Chinese Biomedical Literature Database and China National Knowledge Infrastructure. All eligible randomized controlled trails (RCTs) of conservative interventions for PPUI will be included. R software 3.61 (R Foundation for Statistical Computing, Vienna, Austria) will be applied to synthesize data and conduct network meta-analysis. I statistic and Z test will be used to assess heterogeneity and inconsistency, respectively. RESULTS Ethical approval is not required for this existed literature based meta-analysis. The findings of this research will be disseminated through a recognized journal. CONCLUSION The findings of this study will provide ranking evidence for clinicians and patients to choose a more appropriate conservative therapy on PPUI. TRIAL REGISTRATION NUMBER PROSPERO CRD42020168042.
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Affiliation(s)
- Yang Wang
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine
- Department of Rehabilitation, Shuangliu Maternal and Child Health Care Hospital
| | - Hui Li
- School of Medicine, Chengdu University
| | - Jun Wang
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine
| | - Qinghong Hao
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine
| | - Yang Tu
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine
| | - Yalin Chen
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine
| | - Mimi Qiu
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine
| | - Wei Peng
- School of Acupuncture and Tuina, Chengdu University of Traditional Chinese Medicine
| | - Yunlu Liu
- Institute of Laboratory Animal Sciences
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Tianmin Zhu
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine
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McKnoulty M, Green A, Scott S, Roberts MJ, Kothari A. Spontaneous renal fornix rupture in pregnancy and the post partum period: a systematic review of outcomes and management. BMC Urol 2020; 20:116. [PMID: 32753038 PMCID: PMC7405429 DOI: 10.1186/s12894-020-00660-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 06/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Spontaneous renal fornix rupture (SRFR) causing urinoma is an uncommon but serious condition in pregnancy. Limited information is available to describe the natural history and outcomes to guide appropriate treatment. The aim of this study was to determine the natural history and outcomes of SRFR to determine appropriate management recommendations. METHODS A systematic review of literature databases was performed, using the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) checklist from 1950 - April 2020. Inclusion criteria included any urinary extravasation from the kidney or ureter during pregnancy, or in the 8 weeks following delivery, confirmed via imaging or surgery. Haematomas and non-confirmed cases were excluded. RESULTS A total of 1579 records were originally identified, of which 39 case reports were appropriate for inclusion. SRFR was most commonly reported during the first pregnancy (72%), 19/30 during the third trimester and 9 in the post-natal period. All patients presented with pain, with haematuria positive on urine dipstick in only 36% of 26 reported cases. Ultrasound was the most frequently used imaging modality, resulting in a diagnosis in 42% of cases. All cases reported on treatment procedures including ureteric stents (46%), percutaneous drain (15%), conservative management (15%), nephrostomy (13%) and ureteral catherization (10%). Long term urological outcomes were positive, however women suffering SRFR were significantly more likely to undergo pre-term labour. CONCLUSION While selected cases may be successfully managed conservatively, urinary diversion, through ureteric stents, should be considered the management of choice in these individuals. Clinicians should be mindful of an increased risk of premature delivery and its' associated negative fetal outcomes.
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Affiliation(s)
- Matthew McKnoulty
- Faculty of Medicine, University of Queensland, Herston, 4006 Australia
- Queensland University of Technology, AUSHI, Kelvin Grove, 4059 Australia
- Department of Obstetrics and Gynaecology, Royal Brisbane and Women’s Hospital, Herston, 4006 Australia
| | - Ayla Green
- Faculty of Medicine, University of Queensland, Herston, 4006 Australia
- Department of Obstetrics and Gynaecology, Townsville University Hospital, Douglas, 4814 Australia
| | - Susan Scott
- Department of Urology, Mater Hospital, South Brisbane, 4101 Australia
| | - Matthew J. Roberts
- Faculty of Medicine, University of Queensland, Herston, 4006 Australia
- Department of Urology, Royal Brisbane and Women’s Hospital, Herston, 4006 Australia
| | - Alka Kothari
- Faculty of Medicine, University of Queensland, Herston, 4006 Australia
- Department of Obstetrics and Gynaecology, Redcliffe Hospital, Redcliff, 4020 Australia
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He Z, Cui L, Wang J, Gong F, Jia G. Conservative treatment of patients with bladder genital tract fistula: Three case reports. Medicine (Baltimore) 2020; 99:e21430. [PMID: 32756150 PMCID: PMC7402804 DOI: 10.1097/md.0000000000021430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Most of the patients with bladder genital tract fistula recover with surgical treatment. In the present study, we aimed to assess conservative treatment strategies for bladder genital tract fistula. PATIENT CONCERNS We reviewed 3 cases with bladder genital tract fistula who underwent treatment at our hospital from January to June 2017. Patient 1 underwent cesarean delivery, Patient 2 underwent total abdominal hysterectomy bilateral salpingo-oophorectomy (TAHBSO) and pelvic lymphadenectomy, and Patient 3 underwent extensive TAHBSO and pelvic lymphadenectomy. All 3 patients exhibited involuntary vaginal fluid outflow (average duration, 12.7 days; range, 7-21 days). DIAGNOSIS Patient 1 was diagnosed as vesicouterine fistula by cystosonography and Patient 2, Patient 3 was diagnosed as vesicovaginal fistula by cystoscopy. INTERVENTIONS All 3 patients underwent indwelling urinary catheterization. OUTCOMES No vaginal fluid outflow could be observed after treatment of all 3 patients. CONCLUSION Indwelling urinary catheterization should be administered for suitable patients as conservative treatment. If vesicouterine fistulas that are simple and have a diameter of <0.5 cm can be treated conservatively. If the condition does not resolve after 2 months, surgery should be considered.
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Abstract
Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.
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Affiliation(s)
- Emily E. Naoum
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Andrew Chalupka
- Department of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalBostonMA
| | - Jonathan Haft
- Department of Cardiac SurgeryUniversity of MichiganAnn ArborMI
| | - Mark MacEachern
- Taubman Health Sciences LibraryUniversity of MichiganAnn ArborMI
| | - Cosmas J. M. Vandeven
- Department of Obstetrics and GynecologyMaternal‐Fetal MedicineUniversity of MichiganAnn ArborMI
| | - Sarah Rae Easter
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyBrigham and Women’s HospitalBostonMA
| | - Michael Maile
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of MedicineDepartment of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalBostonMA
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Abstract
Subclinical autoimmune thyroiditis exacerbates after delivery through immune rebound mechanisms and results in 5 types of thyroid dysfunction. The prevalence of postpartum thyroid dysfunction is around 5% in mothers in the general population. Typically, an exacerbation induces destructive thyrotoxicosis followed by transient hypothyroidism, known as postpartum thyroiditis. Late development of permanent hypothyroidism is found frequently and patients should be followed up once every one to two years. Destructive thyrotoxicosis in postpartum thyroiditis should carefully be differentiated from post-partum Graves' disease. Postpartum thyroiditis typically occurs 1-4 months after parturition whereas Graves' disease develops at 4-12 months postpartum. Anti-TSH receptor antibodies (TRAb) are typically positive and thyroid blood flow is high in Graves' disease, whereas these features are absent in postpartum thyroiditis. Postpartum Graves' disease should be treated with antithyroid drugs.
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Affiliation(s)
- Nobuyuki Amino
- Amino Thyroid Research Laboratory, 5-60-38 Nanpeidai, Takatsuki-shi, Osaka, 569-1042, Japan.
| | - Naoko Arata
- Division of Maternal Medicine, Center for Maternal-Fetal-Neonatal and Reproductive Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagayaku, Tokyo, 1578535, Japan.
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Inagawa Y, Okada T, Yasuda M, Sato K, Watanabe R, Kawai T, Umino M, Inoue K, Suda S. Continuous electroconvulsive therapy for a patient with recurrent post-partum psychosis. Asian J Psychiatr 2020; 51:102078. [PMID: 32330689 DOI: 10.1016/j.ajp.2020.102078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/03/2020] [Accepted: 04/02/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Yuta Inagawa
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan.
| | - Tsuyoshi Okada
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan
| | - Manabu Yasuda
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan
| | - Kengo Sato
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan
| | - Ryosuke Watanabe
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan
| | - Tetsuro Kawai
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan
| | - Mami Umino
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan
| | - Koju Inoue
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan
| | - Shiro Suda
- Department of Psychiatry, Jichi Medical University, Tochigi, Japan
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Davis EO, Gibson M, Lim T, Glikman JA. Bear bile use at the intersection of maternal health in Cambodia. J Ethnobiol Ethnomed 2020; 16:28. [PMID: 32448341 PMCID: PMC7245845 DOI: 10.1186/s13002-020-00380-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/11/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The consumption of bear gallbladders and bear bile in Southeast Asia is a persistent threat to bear populations. As part of a larger effort to understand the characteristics of bear part consumption in Cambodia, we uncovered a consumer base of women seeking treatment for post-partum and uterine ailments. METHODS To better understand this aspect of consumption, we interviewed 122 women in seven different provinces in Cambodia, probing into the motivations and influences for using bear bile, as well as what types of ailments Cambodian women use it for. RESULTS We found that it is generally used by young or expecting mothers, and for such issues as post-partum "fatigue" (toas in Khmer), which could encompass post-partum depression. A desire to be supported by kin networks seems to facilitate the continued use of bear gallbladder and bile for these purposes. CONCLUSIONS We suggest that efforts to reduce consumption should focus on encouraging older kin to change their means of support to Western/biomedical and by extension non-wildlife alternatives.
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Affiliation(s)
- Elizabeth Oneita Davis
- San Diego Zoo Institute for Conservation Research, 15600 San Pasqual Valley Rd, Escondido, CA, 92026, USA.
| | - Mhairi Gibson
- Department of Anthropology and Archaeaology, University of Bristol, 43 Woodland Rd, Bristol, BS8 1UU, UK
| | - Thona Lim
- Free the Bears, PO Box 723, Phnom Penh, Cambodia
| | - Jenny Anne Glikman
- San Diego Zoo Institute for Conservation Research, 15600 San Pasqual Valley Rd, Escondido, CA, 92026, USA
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Woodley SJ, Lawrenson P, Boyle R, Cody JD, Mørkved S, Kernohan A, Hay-Smith EJC. Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev 2020; 5:CD007471. [PMID: 32378735 PMCID: PMC7203602 DOI: 10.1002/14651858.cd007471.pub4] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017. OBJECTIVES To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations. SEARCH METHODS We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies. SELECTION CRITERIA We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment). DATA COLLECTION AND ANALYSIS We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE. MAIN RESULTS We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. AUTHORS' CONCLUSIONS This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.
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Affiliation(s)
| | - Peter Lawrenson
- Department of Anatomy, University of Otago, Dunedin, New Zealand
| | - Rhianon Boyle
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - June D Cody
- c/o Cochrane Incontinence, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Siv Mørkved
- Clinical Service, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - E Jean C Hay-Smith
- Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago, Wellington, New Zealand
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Polster SP, Lyne SB, Mansour A. Case Demonstrating the Nuances of Acute Cortical Venous Thrombosis Anticoagulation Guidelines. World Neurosurg 2020; 139:215-218. [PMID: 32304887 DOI: 10.1016/j.wneu.2020.03.220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The American Stroke Association and the European Stroke Organization have established guidelines on cerebral venous thrombosis (CVT); however, questions remain when an individual case does not fall within the inclusion criteria on which these guidelines are based. This is relevant when considering the use of anticoagulation in cases of CVT regarding whether or not associated hemorrhage is present and whether the hemorrhage is currently expanding. CASE DESCRIPTION A 16-year-old right-handed female G2P2 (gravidity 2 [2 pregnancies] and parity 2 [2 live births after at least 24 weeks) presented 8 days postpartum with complaints of slurred speech, right facial droop, and right upper extremity numbness that had progressed over the course of 4 hours before presentation. On imaging the patient had a CVT with associated hemorrhage progressing in size at serial 6-hour stability computed tomography scans for 24 hours post arrival. At 24 hours the patient went into disseminated intravascular coagulation and demonstrated signs of herniation. The patient underwent an emergency hemicraniectomy along with a right frontal external ventricular drain for intracranial pressure monitoring. Most recently, the patient had a Glasgow Coma Scale score of 15 and had a modified Rankin Scale score of 4 and was ultimately discovered to have antiphospholipid syndrome. CONCLUSIONS This case of CVT demonstrates the need for critically reading guidelines, as in this case the time to anticoagulation treatment was shorter than in cases included in guideline construction and repeated computed tomography examination demonstrated expansion suggesting it is unsuitable for immediate anticoagulation. Certain cases may fall outside of the study parameters on which guidelines are constructed, and clinicians should be aware of these exceptions.
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Affiliation(s)
- Sean P Polster
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
| | - Seán B Lyne
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Ali Mansour
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
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Rottenstreich M, Reznick O, Sela HY, Ioscovich A, Grisaro Granovsky S, Weiniger CF, Einav S. Severe Maternal Morbidity Cases in Israel in a High-Volume High-Resource Referral Center: A Retrospective Cohort Study. Isr Med Assoc J 2020; 22:142-147. [PMID: 32147977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Admission to an intensive care unit (ICU) is an objective marker of severe maternal morbidity (SMM). OBJECTIVES To determine the prevalence of obstetric ICU admissions in one medical center in Israel and to characterize this population. METHODS In this retrospective study the files of women coded for pregnancy, birth, or the perinatal period and admission to the ICU were pulled for data extraction (2005-2013). RESULTS During the study period, 111 women were admitted to the ICU among 120,279 women who delivered babies (0.09%). Their average age was 30 ± 6 years, most were multigravida, a few had undergone fertility treatments, and only 27% had complicated previous pregnancies. Most pregnancies (71.2%) were uneventful prior to admission. ICU admissions were divided equally between direct (usually hemorrhage) and indirect (usually cardiac disease) obstetric causes. CONCLUSIONS The indications for obstetrics ICU admission correlated with the proximate causes of maternal arrest observed worldwide. While obstetric hemorrhage is often unpredictable, deterioration of heart disease is foreseeable. Attention should be directed specifically toward improving the diagnosis and treatment of maternal heart disease during pregnancy in Israel.
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Affiliation(s)
- Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Ortal Reznick
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Alexander Ioscovich
- Department of Anesthesiology, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Sorina Grisaro Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Carolyn F Weiniger
- Division of Anesthesia and Critical Care and Pain, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sharon Einav
- Department of Intensive Care, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
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Abstract
Thyroiditis is a frequent and mostly benign disease that can sometimes disrupt the thyroid balance. Their diagnosis, as well as their aetiology, is a necessary step in the management of the patients. Painful thyroiditis includes acute thyroiditis of infectious origin and subacute thyroiditis. The first one can be treated by antibiotics or antifungals depending on the germ found. The second one will be treated with non-steroidal anti-inflammatory drugs or corticosteroids. In cases of Hashimoto's thyroiditis with overt hypothyroidism, replacement therapy with L-thyroxine will be adapted to the TSH level. As amiodarone treatment provides dysthyroidism, the thyroid status should be monitored regularly. Hypothyroidism will be treated using thyroid replacement therapy. Hyperthyroidism imposes a stop of amiodarone when it is possible. Treatment with synthetic antithyroid drugs (propyl-thio-uracil) or corticosteroids could be used whether there is an underlying thyroid disease or not. Immunotherapies with anti-PD-1/PDL1 or anti-CTLA-4 can also provide dysthyroidism. A monitoring of the thyroid assessment needs to be done in these patients, even if there are no clinical signs, which are not very specific in this context. The treatment of hypothyroidism will be based on thyroid replacement therapy according to the TSH level and the presence or absence of anti-TPO antibodies. Treatment of symptomatic hyperthyroidism may involve a prescription of beta-blockers, or synthetic antithyroid drugs in case of positive anti-TSH receptor antibodies. In all cases, it is desirable to contact an endocrinologist to confirm the diagnosis hypothesis and to decide on a suitable treatment.
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Affiliation(s)
- A Rouland
- Service d'endocrinologie, diabétologie, maladies métaboliques, CHU de Dijon, 2, boulevard Maréchal-de-Lattre-de-Tassigny, 21000 Dijon, France; Unité Inserm LNC-UMR 1231, université de Bourgogne-Franche-Comté, Dijon, France
| | - P Buffier
- Service d'endocrinologie, diabétologie, maladies métaboliques, CHU de Dijon, 2, boulevard Maréchal-de-Lattre-de-Tassigny, 21000 Dijon, France
| | - J-M Petit
- Service d'endocrinologie, diabétologie, maladies métaboliques, CHU de Dijon, 2, boulevard Maréchal-de-Lattre-de-Tassigny, 21000 Dijon, France; Unité Inserm LNC-UMR 1231, université de Bourgogne-Franche-Comté, Dijon, France
| | - B Vergès
- Service d'endocrinologie, diabétologie, maladies métaboliques, CHU de Dijon, 2, boulevard Maréchal-de-Lattre-de-Tassigny, 21000 Dijon, France; Unité Inserm LNC-UMR 1231, université de Bourgogne-Franche-Comté, Dijon, France
| | - B Bouillet
- Service d'endocrinologie, diabétologie, maladies métaboliques, CHU de Dijon, 2, boulevard Maréchal-de-Lattre-de-Tassigny, 21000 Dijon, France; Unité Inserm LNC-UMR 1231, université de Bourgogne-Franche-Comté, Dijon, France.
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Johnson O, Pouncey AL, Gardiner S, Ross D. A woman with spreading erythema after caesarean section. BMJ 2020; 368:m445. [PMID: 32107271 DOI: 10.1136/bmj.m445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | | | | | - David Ross
- Guy's and St Thomas' Hospital, London, UK
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38
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Oblizajek NR, Anavekar NS. 26-Year-Old Woman With Shortness of Breath and Chest Pain. Mayo Clin Proc 2020; 95:378-383. [PMID: 32029090 DOI: 10.1016/j.mayocp.2019.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Nicholas R Oblizajek
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Nandan S Anavekar
- Advisor to resident and Consultant in Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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39
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Stumpf T, Mattsson G, Magnusson P. [Peripartum cardimyopathy - risk of delayed diagnosis]. Lakartidningen 2020; 117:FSS7. [PMID: 31990362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Peripartum cardiomyopathy is defined as heart failure, with ejection fraction less than 45% that presents late during pregnancy or the first five months postpartum. Despite being described first in 1849 by Ritchie the mechanisms behind the disease are still not fully understood. However, oxidative stress during pregnancy and the cleavage of prolactine into its 16 kDa fragment appears to play a role in the pathophysiology of peripartum cardiomyopathy. In addition to optimal therapy for heart failure bromocriptine, an inhibitor of prolactine release, should be considered. Prevalence and prognosis varies geographically. Most often left ventricular ejection fraction is normalized after six months but sometimes the disease is associated with deteriorating heart failure and death. Therefore it is important for health care professionals caring for women in the peripartum period to be aware of the signs and symptoms of the diagnosis.
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Affiliation(s)
- Tamás Stumpf
- Region Jönköpings län - Länssjukhuset Ryhov Jönköping, Sweden Region Jönköpings län - Länssjukhuset Ryhov Jönköping, Sweden
| | - Gustav Mattsson
- Uppsala Universitet, Centrum för forskning och utveckling, Region Gävleborg, Gävle, Sweden
| | - Peter Magnusson
- Uppsala Universitet - Centrum för forskning och utveckling, Uppsala, Sweden, Region Gävleborg, Gävle Sweden Uppsala Universitet - Centrum för forskning och utveckling, Uppsala, Sweden Region Gävleborg, Gävle Sweden
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Dong AC, Stephenson MD, Stagnaro-Green AS. The Need for Dynamic Clinical Guidelines: A Systematic Review of New Research Published After Release of the 2017 ATA Guidelines on Thyroid Disease During Pregnancy and the Postpartum. Front Endocrinol (Lausanne) 2020; 11:193. [PMID: 32318026 PMCID: PMC7154179 DOI: 10.3389/fendo.2020.00193] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/18/2020] [Indexed: 12/19/2022] Open
Abstract
Background: The American Thyroid Association Guidelines on Thyroid Disease During Pregnancy and the Postpartum (ATA Guidelines) were published in 2017, with an update not expected for another 5 years. Since release of the 2017 ATA Guidelines, greater than 500 articles have been published in the field. Furthermore, there are presently 14 prospective, interventional trials in progress registered at Clinicaltrials.gov Static guidelines updated every 5-7 years fail to provide timely evidence-based guidance to practicing clinicians. Consequently, guideline development should move toward the creation of dynamic documents. The present article reviews the literature published since the 2017 ATA Guidelines, both to benefit clinicians in practice and to make the case for Dynamic ATA Guidelines. Methods: Using the search terms "thyroid" and "pregnancy," a systematic review of literature published in Pubmed from 3/1/2017 to 12/31/2018 was conducted. The titles and/or abstracts of all articles were reviewed. All articles were classified by subject headings used in the 2017 ATA Guidelines. English-text articles classified under "hypothyroidism" or "thyroid autoimmunity" were examined in full-text. Using the questions and recommendations put forth by the previous ATA Guidelines, relevant articles were selected for discussion in this review. Results: At the time of the search, 659 unique articles on "thyroid and pregnancy" were identified, including 66 original studies on hypothyroidism and 26 on thyroid autoimmunity. Of these, 26 studies on hypothyroidism and 18 studies on thyroid autoimmunity were selected for inclusion in this review based on specific questions in the 2017 ATA Guidelines. Based on these 44 articles, we propose two specific changes to the 2017 ATA Guidelines. Conclusion: Based on new research, we recommend the 2017 ATA Guidelines be updated to recommend against treating thyroid antibody-negative women diagnosed with subclinical hypothyroidism in the second trimester or later; to reflect new, moderate-quality evidence supporting the treatment of thyroid peroxidase antibody-negative women with elevated thyroid stimulating hormone levels in the first trimester or earlier; and to recommend against treatment of euthyroid, thyroid peroxidase antibody-positive women undergoing assisted reproductive technology. Transitioning to a Dynamic ATA Guidelines would allow for these and future recommendations to be implemented in real time.
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Affiliation(s)
- Allan C. Dong
- Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Chicago, Chicago, IL, United States
- Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, IL, United States
| | - Mary D. Stephenson
- Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Chicago, Chicago, IL, United States
| | - Alex Stewart Stagnaro-Green
- Department of Medicine, Obstetrics & Gynecology and Medical Education, University of Illinois College of Medicine at Rockford, Rockford, IL, United States
- *Correspondence: Alex Stewart Stagnaro-Green
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Forde R, Peters S, Wittkowski A. Psychological interventions for managing postpartum psychosis: a qualitative analysis of women's and family members' experiences and preferences. BMC Psychiatry 2019; 19:411. [PMID: 31856785 PMCID: PMC6923990 DOI: 10.1186/s12888-019-2378-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 11/27/2019] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Postpartum psychosis is a rare, yet severe disorder, in which early identification and immediate intervention are crucial. Despite recommendations for psychological input, little is known about the types of psychological intervention reported to be helpful. The aim of this study was to explore the experiences, needs and preferences for psychological intervention from the perspective of women with postpartum psychosis and from the perspective of family members. METHODS Thirteen women and eight family members, including partners were interviewed. The data from these semi-structured interviews were audio-recorded, transcribed and inductively analysed using thematic analysis. RESULTS Twelve subthemes were identified and then organised around three main themes: 1) Seeking safety and containment, 2) Recognising and responding to the psychological impact and 3) Planning for the future. These themes highlight the temporal element of recovery from postpartum psychosis, because women's psychological needs and preferences changed over time. Emphasis was initially placed on ensuring safety, followed by a need to connect, process and adjust to their experiences. Additional needs were reported by women and family when planning for the future, including managing the fear of relapse and help to reach a decision about future pregnancies. CONCLUSION The results illustrate a range of areas in which psychological intervention could be delivered to facilitate and enhance recovery. Further research is needed to develop meaningful and effective psychological interventions and to investigate the most appropriate timing for this to be offered.
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Affiliation(s)
- R Forde
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Zochonis Building, Brunswick Street, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - S Peters
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Zochonis Building, Brunswick Street, Manchester, M13 9PL, UK
| | - A Wittkowski
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Zochonis Building, Brunswick Street, Manchester, M13 9PL, UK.
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK.
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Stepien KM, Geberhiwot T, Hendriksz CJ, Treacy EP. Challenges in diagnosing and managing adult patients with urea cycle disorders. J Inherit Metab Dis 2019; 42:1136-1146. [PMID: 30932189 DOI: 10.1002/jimd.12096] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/28/2019] [Indexed: 12/15/2022]
Abstract
Urea cycle disorders (UCD) are a group of rare inherited metabolic conditions of amino acid catabolism caused by an enzyme deficiency within the hepatic ammonia detoxification pathway. The presentation of these disorders ranges from life-threatening intoxication in the neonate to asymptomatic status in adults. Late-onset UCDs can present for the first time in adulthood and may mimic other causes of acute confusion or psychiatric diseases, and are often associated with neurological symptoms. Late-onset UCDs may become apparent during periods of metabolic stress such as rapid weight loss, gastric bypass surgery, chronic starvation or the postpartum period. Early diagnosis is critical for effective treatment and to prevent long-term complications of hyperammonemia. The challenges of management of adults include for example: (a) poor compliance to dietary and medical treatment which can result in recurrent hospital admissions; (b) severe neurological dysfunction; (c) the management of pregnancy and the postpartum period; and (d) access to multidisciplinary care peri-operatively. In this review, we highlight a number of challenges in the diagnosis and management of adult patient with late-onset UCDs and suggest a systematic management approach.
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Affiliation(s)
- Karolina M Stepien
- Mark Holland Metabolic Unit, Adult Inherited Metabolic Diseases Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Tarekegn Geberhiwot
- Centre for Endocrinology, Diabetes and Metabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Christian J Hendriksz
- Department of Paediatrics, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
| | - Eileen P Treacy
- National Centre for Inherited Metabolic Diseases, The Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Paediatrics, Trinity College, Dublin, Ireland
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43
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Abstract
RATIONALE Postpartum deep vein thrombosis is a unique condition in diagnosis and treatment. Rivaroxaban, a novel oral anticoagulant, is indicated for acute deep vein thrombosis, but limited data have been reported for postpartum women. Catheter-directed thrombolysis is a common procedure for treating acute deep vein thrombosis, but it is rarely used for postpartum patients, especially after more than 3 months. PATIENT CONCERNS A 31-year-old Asian woman suffered from progressive erythematous swelling and local heat of the left lower limb after twin delivery. DIAGNOSES Venous duplex ultrasound examination showed thrombus formation in the left femoral vein and popliteal vein with reduced compressibility. After standard treatment of novel oral anticoagulant therapy for 4 months, we observed only partial improvement of the symptoms, and the condition deteriorated after her ordinary activities. INTERVENTIONS Venography was performed and a large amount of thrombus lining from left femoral vein to left iliac vein was noted with total occluded left common iliac vein. After catheter-directed thrombolysis and balloon dilatation, better flow was regained and her symptoms improved completely after procedure. OUTCOMES During a 1-year follow-up without medication, the patient did not complain about leg swelling, exercise aggravation, or any other post-thrombotic symptoms. LESSONS Pregnancy seems to be a transient provoking factor for deep vein thrombosis, but it is sometimes refractory even during the postpartum period.Follow-up imaging studies should be encouraged to confirm the vessel condition, particularly for applying down-titration or discontinuation strategies of medication.Catheter-directed thrombolysis could be considered as an alternative method for postpartum iliofemoral deep vein thrombosis. Postpartum women usually have favorable functional status and lower bleeding risk.Rivaroxaban is a favorable choice for deep vein thrombosis, but its use in postpartum women is still controversial, and evidence of its effectiveness is not available. Thus, endovascular intervention can be a relatively safe therapy, in addition to anticoagulation therapy for premenopausal patients with recurrent deep vein thrombosis.
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Affiliation(s)
- Po-Wei Chen
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ping-Yen Liu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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44
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Haire-Joshu D, Cahill AG, Stein RI, Cade WT, Woolfolk CL, Moley K, Mathur A, Schwarz CD, Schechtman KB, Klein S. Randomized Controlled Trial of Home-Based Lifestyle Therapy on Postpartum Weight in Underserved Women with Overweight or Obesity. Obesity (Silver Spring) 2019; 27:535-541. [PMID: 30900408 PMCID: PMC6526535 DOI: 10.1002/oby.22413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/21/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to assess the efficacy of a home-based lifestyle intervention delivered through Parents as Teachers (PAT), a national home-visiting organization, designed to minimize excessive weight gain through 12 months post partum in socioeconomically disadvantaged (SED) African American women with overweight or obesity. METHODS This randomized controlled trial was conducted at a single center as part of the Lifestyle Interventions for Expectant Moms (LIFE-Moms) consortium. Analysis was conducted with 185 SED African American women (BMI 25.0-45.0 kg/m2 at pregnancy onset) retained from an original sample of 267 randomized to standard PAT or PAT+Lifestyle, which embedded lifestyle therapy within standard PAT delivered prenatally and for 12 months post partum. RESULTS Compared with standard PAT, the PAT+Lifestyle group gained less weight (2.5 kg vs. 5.7 kg; P = 0.01) and were more likely to return to their baseline weight (38.0% vs. 21.5%; P = 0.01) from baseline to 12 months post partum. There were no differences between groups in cardiometabolic outcomes, indices of glycemic control and insulin sensitivity, and plasma lipid profile. The estimated cost of PAT+Lifestyle was $81 more to deliver per family than standard PAT. CONCLUSIONS PAT+Lifestyle decreases weight gain during pregnancy through 12 months post partum in SED African American women with overweight or obesity at the start of pregnancy with minimal additional cost.
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Affiliation(s)
- Debra Haire-Joshu
- Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Richard I Stein
- Center for Human Nutrition, Washington University in St. Louis, St. Louis, Missouri, USA
| | - W Todd Cade
- Program in Physical Therapy, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Candice L Woolfolk
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kelle Moley
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Amit Mathur
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Cynthia D Schwarz
- Brown School, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kenneth B Schechtman
- Department of Biostatistics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Samuel Klein
- Center for Human Nutrition, Washington University in St. Louis, St. Louis, Missouri, USA
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Trevillion K, Shallcross R, Ryan E, Heslin M, Pickles A, Byford S, Jones I, Johnson S, Pawlby S, Stanley N, Rose D, Seneviratne G, Wieck A, Jennings S, Potts L, Abel KM, Howard LM. Protocol for a quasi-experimental study of the effectiveness and cost-effectiveness of mother and baby units compared with general psychiatric inpatient wards and crisis resolution team services (The ESMI study) in the provision of care for women in the postpartum period. BMJ Open 2019; 9:e025906. [PMID: 30904867 PMCID: PMC6475160 DOI: 10.1136/bmjopen-2018-025906] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Research into what constitutes the best and most effective care for women with an acute severe postpartum mental disorder is lacking. The effectiveness and cost-effectiveness of psychiatric mother and baby units (MBUs) has not been investigated systematically and there has been no direct comparison of the outcomes of mothers and infants admitted to these units, compared with those accessing generic acute psychiatric wards or crisis resolution teams (CRTs). Our primary hypothesis is that women with an acute psychiatric disorder, in the first year after giving birth, admitted to MBUs are significantly less likely to be readmitted to acute care (an MBU, CRTs or generic acute ward) in the year following discharge than women admitted to generic acute wards or cared for by CRTs. METHODS AND ANALYSIS Quasi-experimental study of women accessing different types of acute psychiatric services in the first year after childbirth. Analysis of the primary outcome will be compared across the three service types, at 1-year postdischarge. Cost-effectiveness will be compared across the three service types, at 1-month and 1-year postdischarge; explored in terms of quality-adjusted life years. Secondary outcomes include unmet needs, service satisfaction, maternal adjustment, quality of mother-infant interaction. Outcomes will be analysed using propensity scoring to account for systematic differences between MBU and non-MBU participants. Analyses will take place separately within strata, defined by the propensity score, and estimates pooled to produce an average treatment effect with weights to account for cohort attrition. ETHICS AND DISSEMINATION The study has National Health Service (NHS) Ethics Approval and NHS Trust Research and Development approvals. The study has produced protocols on safeguarding maternal/child welfare. With input from our lived experience group, we have developed a dissemination strategy for academics/policy-makers/public.
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Affiliation(s)
- Kylee Trevillion
- Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Rebekah Shallcross
- Centre for Academic Primary Care, University of Bristol Medical School, Bristol, UK
| | - Elizabeth Ryan
- Biostatistics Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Margaret Heslin
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Andrew Pickles
- Biostatistics Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Ian Jones
- National Centre for Mental Health, Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | - Susan Pawlby
- Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Nicky Stanley
- School of Social Work, Care and Community, University of Central Lancashire, Preston, UK
| | - Diana Rose
- Service User Research Enterprise, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Gertrude Seneviratne
- Psychological Medicine and Integrated Care Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
| | - Angelika Wieck
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Stacey Jennings
- Addictions, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Laura Potts
- Biostatistics Department, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
| | - Kathryn M Abel
- Medical and Human Sciences, Institute of Brain Behaviour and Mental Health, Manchester, UK
- Manchester Mental Health & Social Care Trust, Manchester, UK
| | - Louise M Howard
- Section of Women's Mental Health, Institute of Psychiatry, Psychology & Neuroscience at King's College London, London, UK
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46
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Affiliation(s)
- Ina Dubin
- Department of Medicine, Laniado Hospital, Sanz Medical Centre, Netanya, Israel
| | - Yair Glick
- Department of Imaging, Laniado Hospital, Sanz Medical Centre, Netanya, Israel
| | - Amichai Schattner
- Department of Medicine, Laniado Hospital, Sanz Medical Centre, Netanya, Israel
- The Faculty of Medicine, Hebrew University Hadassah Medical School, Jerusalem, Israel
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47
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Abstract
A 19-year-old primigravida had a normal vaginal delivery after a 90-minute second stage of labour. Within two hours she complained of dyspnoea and was noticed to have unusual swelling of the face and neck. The diagnosis of subcutaneous emphysema was confirmed by chest X-ray and pneumomediastinum was also detected. Uneventful recovery over four days followed conservative management, administration of oxygen and use of simple analgesics.
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Affiliation(s)
- B L Duffy
- Obstetric Anaesthetic Services, Queen Elizabeth Hospital, Adelaide, South Australia
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48
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Abstract
Postpartum psychosis is a psychiatric emergency that affects 1 to 2 per 1000 women. Key clinical features include mood fluctuation, abnormal thoughts or behaviors, and confusion. Women with a history of bipolar disorder are at heightened risk, as are first-time mothers; current research on the causes focuses on biological triggers, such as immune dysregulation. Women with postpartum psychosis require inpatient hospitalization and should be treated with lithium, antipsychotics, and benzodiazepines.
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Affiliation(s)
- Lauren M Osborne
- Departments of Psychiatry & Behavioral Sciences and Gynecology & Obstetrics, Women's Mood Disorders Center, Johns Hopkins University School of Medicine, 550 North Broadway, Suite 305, Baltimore, MD 21205, USA.
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Ahmadzia HK, Phillips JM, James AH, Rice MM, Amdur RL. Predicting peripartum blood transfusion in women undergoing cesarean delivery: A risk prediction model. PLoS One 2018; 13:e0208417. [PMID: 30551126 PMCID: PMC6294610 DOI: 10.1371/journal.pone.0208417] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/18/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE There has been an appreciable rise in postpartum hemorrhage requiring blood transfusions in the United States. Our objective is to better define patients at greatest risk for peripartum transfusion at the time of cesarean in order to identify cases for early intervention and monitoring. METHODS Our study is a secondary analysis of a retrospective cohort study. Cases of intraoperative and immediate postpartum blood transfusion among women undergoing cesarean delivery were identified. Multivariable logistic regression models were used to identify antepartum and intrapartum risk factors that were independently associated with blood transfusion. A risk calculator was then developed to predict the need for transfusion. RESULTS Of 56,967 women, 1488 (2.6%) required any blood transfusion. The strongest risk factors for peripartum blood transfusion included anemia (odds ratio [OR] 3.7, 95% CI 3.3-4.3), abruption on presentation (OR 3.3, CI 2.6-4.1), general anesthesia (OR 5.2, CI 4.4-6.1) and abnormal placentation (OR 92.0, CI 57.4-147.6). An antepartum (model 1) and combined antepartum plus intrapartum risk model (model 2) were developed (model 1 AUC = 0.77, model 2 AUC = 0.83) and internally validated. CONCLUSIONS Among women who required cesarean delivery, we were able to identify risk factors which predispose women to peripartum blood transfusion and developed a prediction model with good discrimination.
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Affiliation(s)
- Homa K. Ahmadzia
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, United States of America
| | - Jaclyn M. Phillips
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, George Washington University, Washington, DC, United States of America
| | - Andra H. James
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine and Department of Medicine, Division of Hematology, Duke University, Durham, NC, United States of America
| | - Madeline M. Rice
- Department of Epidemiology and Biostatistics and the Biostatistics Center, George Washington University, Washington, DC, United States of America
| | - Richard L. Amdur
- Department of Surgery, George Washington University, Washington, DC, United States of America
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50
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Affiliation(s)
- Matthieu Jamme
- Renal Intensive Care Unit and Kidney Transplantation, Tenon University Hospital, Sorbonne Université Pierre et Marie Curie University, Assistance Publique-Hôpital de Paris, Paris, France.
| | - Cédric Rafat
- Renal Intensive Care Unit and Kidney Transplantation, Tenon University Hospital, Sorbonne Université Pierre et Marie Curie University, Assistance Publique-Hôpital de Paris, Paris, France
| | - Samuel Gaugain
- Department of Anesthesiology and Intensive Care Medicine, Saint Louis Lariboisière University Hospital, University Paris Diderot, Assitance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin G Chousterman
- Department of Anesthesiology and Intensive Care Medicine, Saint Louis Lariboisière University Hospital, University Paris Diderot, Assitance Publique-Hôpitaux de Paris, Paris, France; Institut National de la Santé et de la Recherche Médicale U1160, Hôpital Saint-Louis, Paris, France
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