Primary postpartum hemorrhage

Postpartum hemorrhage is the outstanding cause of maternal mortality, and a redoubtable contributor to puerperal death from other causes, notably infection and renal failure. The clinical situations in which hemorrhage is liable to occur must be better known, so that anticipatory and preventive measures can be taken. Recent knowledge about defibrinated blood in women with degenerative changes at the placental site must be incorporated in the thinking and practice of physicians dealing with obstetrical cases. The indications, limitations, and hazards of the various anesthetic methods available for parturient women should be carefully considered in the circumstances of each case.     

Insulinoma diagnosed in the postpartum: clinical and immunohistochemical features

Insulinomas are rare pancreatic β-cell tumors with an estimated incidence of 1:250.000 persons/year. We present a novel case of insulinoma manifesting immediately after childbirth. Eight days after delivery, a 21-year-old, previously healthy woman presented paresthesia in hands, upper and lower limbs muscle weakness with difficult walking, which worsened during breastfeeding sessions. Laboratory tests showed blood glucose levels between 37 and 55 mg/dL with inappropriately normal insulin levels (7.78 μUI/mL; normal range: 5-29). An abdominal computed tomography showed a nodular lesion measuring 2 cm at the head of the pancreas. Tumor enucleation resulted in complete resolution of hypoglycemia. Histopathological and immunohistochemical analysis were consistent with an insulinoma. About 27 cases of insulinoma associated with pregnancy have been reported to date, mostly diagnosed before the 16th week. The beginning of symptoms soon after delivery is less common. Understanding the interactions between pancreatic β-cell function and all the physiological metabolic and hormonal adaptations associated with gestation is essential for the adequate management of hypoglycemic disorders in pregnant women.     

Mice: postpartum aggression is elevated following prenatal progesterone exposure

Pregnant Rockland-Swiss (R-S) mice were injected with sesame oil or 250 or 500 micrograms of progesterone (P) on Days 12 through 16 of gestation and the postpartum aggressive behavior of their female offspring was examined in adulthood. Both doses of P significantly increased the intensity of aggression (number of attacks) exhibited by the female offspring toward an adult male intruder. The low dose of P also produced significant increases in relative anogenital distance. These effects were seen in the absence of any effects on body weight at birth or in adulthood, or on reproductive performance. The findings support previous research, in both animals and humans, showing that prenatal brain differentiation and subsequent behavior are masculinized by prenatal exposure to progesterone.     

Glioblastoma multiforme presenting as postpartum depression: a case report

Background

Alterations of mental status are characteristic of psychiatric disorders but may also result from a multitude of organic causes. Generally, physical examination and blood analysis are a part of basic psychiatric differential diagnostics, whereas more sophisticated procedures (for example, brain imaging) are applied only in cases with pathologic diagnostic findings. Our report challenges this approach by describing a case of glioblastoma multiforme presenting as postpartum depression without abnormalities in basic differential diagnostics.

Case presentation

A 28-year-old white woman who had been in outpatient treatment for postpartum depression was taken to the psychiatric emergency room. The psychopathological assessment, however, showed mild disorientation and severe deficits of long-term memory. Moreover, she complained of stabbing, bilateral headaches, but results of her physical examination and blood analysis were unremarkable. Magnetic resonance imaging of the brain was performed, which showed a contrast-enhanced mass lesion in the left frontal lobe. The patient underwent urgent tumor resection, and histologic results revealed an IDH-mutant glioblastoma multiforme. The patient was discharged with a substantially improved psychopathology and without neurological deficits.

Conclusions

This report adds to the evidence that postpartum depression may have organic causes in some cases, a fact that needs to be considered in the clinical setting. Atypical neurocognitive findings in a psychiatric interview may alone justify brain imaging, despite normal physical examination and blood analysis results.

     

The postpartum buffalo: I. Endocrinological changes and uterine involution

To maintain a calving interval of 13-14 months in buffaloes, successful breeding must take place within 85-115 days after calving. Disturbances during this period due to delay of uterine involution or resumption of estrous activity are likely to prolong the calving interval and reduce the lifetime reproductive and productive efficiency. In this article literature on endocrinological changes in the peripartum period and on factors affecting uterine involution are reviewed. The available information indicated that although the availability of releasable FSH does not appear to be a limiting factor for resumption of postpartum cyclicity a substantial increase of releasable LH and replenishment of pituitary stores occurred around Day 20 in dairy and Day 30 in swamp buffaloes. There is evidence that follicular activity is resumed early (15-30 days) in the postpartum period. However, the factors which initiate release of appropriate LH pulses, follicular maturation and ovulation in the postpartum buffalo need further studies. The mean interval to complete uterine involution varied widely between 19 and 52 days. Assessment of cervical and uterine horn diameters by rectal palpation alone is not satisfactory to diagnose delayed uterine involution and possible subclinical uterine infection. Vaginal inspection can be included as a fundamental part of postpartum genital examination for diagnosis of such case. Uterine involution, however, does not seem to be a limiting factor for achievement of satisfactory fertility in the postpartum buffalo but the main determinant is resumption of estrous activity.     

Induction of ovulation in postpartum suckled beef cows: a review

Prolonged postpartum acyclicity in suckled beef cows reduces the calf crop, and causes economic loss to beef cattle producers. Once anterior pituitary LH stores have been replenished between Days 15 and 30 post partum in suckled beef cows, methods to initiate cyclicity include non-hormonal methods such as weaning of calves (either complete, temporary or partial), or exposure to bulls, and hormonal methods such as administration of GnRH (either single injection, intermittent injections, or continuous infusion), gonadotropins (eCG, FSH, hCG), and steroids (estrogens, anti-estrogens, and progestogens). Weaning is costly, reduces growth rate of weaned calves, and short cycles are common after weaning-induced ovulation. Exposure of cows to bulls is not practical and its effect is not predictable. Repeated injections of GnRH, or a single injection of hCG are not always effective; ovulation is always followed by a short cycle, and usually a return to acyclicity. Estrogens and anti-estrogens do not consistently shorten postpartum anestrus. Exogenous progestogens include intravaginal devices, such as controlled-internal drug release (CIDR) or progesterone-releasing intravaginal device (PRID), norgestomet implants, and the feed-additive melengestrol acetate (MGA). Administration of exogenous progestogens is more practical than, and offers more advantages over, other treatments to shorten postpartum acyclicity in suckled beef cows. Mimicking the short cycle after Week 3 post partum, by maintaining circulating progesterone at subluteal concentrations or circulating progestin at intermediate concentrations, extends the life-span and allows terminal maturation of the postpartum dominant follicle as in cyclic cows, by initiating endogenous GnRH and LH pulses. This is followed by an LH surge, ovulation and normal cycles. The benefit from using exogenous progestogens after Week 3 post partum in suckled beef cows is that ovulation is induced, cyclicity is initiated, the resulting CL has a normal life-span and function, and there is no need to change management, such as weaning of calves. We present a model for the induction of ovulation and initiation of cyclicity using exogenous progestogens after Week 3 post partum in suckled beef cows.     

Oxytocin during pregnancy and early postpartum: individual patterns and maternal-fetal attachment

Oxytocin (OT), a nanopeptide hormone, plays a role in the emergence of maternal behavior, yet few studies examined OT in humans across pregnancy and the postpartum. We followed healthy women at three points: first trimester of pregnancy, third trimester, and first postpartum month. Plasma OT levels showed high individual stability. A third of the sample showed consistent OT levels, whereas others showed increasing or decreasing trends or peak in late pregnancy. The increase in OT from early to late pregnancy correlated with higher maternal-fetal bonding. These data may help set standards for OT levels and underscore links with maternal-infant attachment.     

Defining postpartum uterine disease in cattle

Uterine function is often compromised in cattle by bacterial contamination of the uterine lumen after parturition, and pathogenic bacteria often persist, causing uterine disease, a key cause of infertility in cattle. However, the definition or characterization of uterine disease frequently lacks precision or varies among research groups. The aim of the present paper was to provide clear clinical definitions of uterine disease that researchers could adopt. Puerperal metritis should be defined as an animal with an abnormally enlarged uterus and a fetid watery red-brown uterine discharge, associated with signs of systemic illness (decreased milk yield, dullness or other signs of toxemia) and fever > 39.5 degrees C, within 21 days after parturition. Animals that are not systemically ill, but have an abnormally enlarged uterus and a purulent uterine discharge detectable in the vagina, within 21 days post partum, may be classified as having clinical metritis. Clinical endometritis is characterised by the presence of purulent (> 50% pus) uterine discharge detectable in the vagina 21 days or more after parturition, or mucuopurulent (approximately 50% pus, 50% mucus) discharge detectable in the vagina after 26 days post partum. In the absence of clinical endometritis, a cow with subclinical endometritis is defined by > 18% neutrophils in uterine cytology samples collected 21-33 days post partum, or > 10% neutrophils at 34-47 days. Pyometra is defined as the accumulation of purulent material within the uterine lumen in the presence of a persistent corpus luteum and a closed cervix. In conclusion, we have suggested definitions for common postpartum uterine diseases, which can be readily adopted by researchers and veterinarians.     

GABA(A)R plasticity during pregnancy: relevance to postpartum depression

Fluctuating neurosteroid levels over the ovarian cycle modulate neuronal excitability through effects on GABA(A) receptors (GABA(A)Rs). The large increase in progesterone-derived neurosteroids during pregnancy and their precipitous decline at parturition may have considerable effects on GABA(A)Rs during pregnancy and postpartum. Here we show a significant decrease in tonic and phasic inhibitions in pregnant mice, mediated by a downregulation of GABA(A)R delta and gamma2 subunits, respectively, which rebounds immediately postpartum. Mice which do not exhibit GABA(A)R delta subunit regulation throughout pregnancy (Gabrd(+/-) and Gabrd(-/-)) exhibit depression-like and abnormal maternal behaviors, resulting in reduced pup survival. These abnormal postpartum behaviors were ameliorated in Gabrd(+/-) mice by a GABA(A)R delta-subunit-selective agonist, THIP. We suggest that Gabrd(+/-) and Gabrd(-/-) mice constitute a mouse model of postpartum depression that may be useful for evaluating potential therapeutic interventions.     

Affective changes during the postpartum period: Influences of genetic and experiential factors

This article is part of a Special Issue “Parental Care”.The postpartum period involves some truly transformational changes in females' socioemotional behaviors. For most female laboratory rodents and women, these changes include an improvement in their affective state, which has positive consequences for their ability to sensitively care for their offspring. There is heterogeneity among females in the likelihood of this positive affective change, though, and some women experience elevated anxiety or depression (or in rodents anxiety- or depression-related behaviors) after giving birth. We aim to contribute to the understanding of this heterogeneity in maternal affectivity by reviewing selected components of the scientific literatures on laboratory rodents and humans examining how mothers' physical contact with her infants, genetics, history of anxiety and depression and early-life and recent-life experiences contribute to individual differences in postpartum affective states. These studies together indicate that multiple biological and environmental factors beyond female maternal state shape affective responses during the postpartum period, and probably do so in an interactive manner. Furthermore, the similar capacity of some of these factors to modulate anxiety and depression in human and rodent mothers suggests cross-species conservation of mechanisms regulating postpartum affectivity.     

Bacteriological investigation of the postpartum uterus: Relationship to involution and histopathological findings

A bacteriological investigation of the postpartum uteri of suckled and nonsuckled Bunaji (White Fulani) cows was undertaken to determine the microflora, the effect of suckling on the flora and the influence of the flora on uterine involution and histopathology. Uterine contamination by bacteria was highest between days 10 and 21 postpartum with Staphylococcus aureus being the commonest organism isolated. There was no consistent isolation of one type of bacterial organism from a cow throughout the sampling period. Suckling did not affect the incidence of uterine contamination by bacteria. Foci of leucocytes (mainly lymphocytes) were found in uterine sections in an increasing frequency with days postpartum. Bacteria were isolated from only 3 of the 12 uteri that had the leucocytic foci. Uterine involution was normal and complete by 25 days after calving irrespective of the presence or absence of bacteria or leucocytic foci. We concluded that postpartum uterine contamination by bacteria was not influenced by suckling and that puerperal uterine contamination by bacteria did not interfere with the normal process and duration of uterine involution.     

Men's experience of their partners' postpartum psychiatric disorders: narratives from the internet

Objectives Postpartum psychiatric disorders (PPPD) can be serious and disabling, and may lead to long-term adverse consequences. Partners of women with PPPD are also affected by the illness, but their experiences are seldom described. The aim of this study was to explore men's experience of women with PPPD.Methods Eleven written narratives from the internet were used to analyse men's perceived experience of their partner's PPPDs. Data were analysed using content analysis.Results The men revealed a major disruption in their lives. They expressed fear, confusion and anger; they were also extremely concerned about their partners, and felt unable to help in overcoming the disorder. Most of the men described making sacrifices in order to hold the relationship and the family together. Although the disorder improved over time, they were left to face an uncertain future with a woman who seemed to be very different from the person they had known previously. Most of the men gained maturity and increased self-esteem, but for some the result was divorce, custody disputes and loneliness.Conclusions The men in this study experienced the woman's PPPD as a difficult time, when everything familiar was turned upside down. Health professionals should pay more attention to men's mental health in the postpartum period. Furthermore, information regarding the possibility of these disorders should be given to expectant couples in prenatal classes. Further research is needed to ascertain how and to what extent this should be included in the education.     

Body temperature in early postpartum dairy cows

A strategy widely adopted in the modern dairy industry is the introduction of postpartum health monitoring programs by trained farm personnel. Within these fresh cow protocols, various parameters (e.g., rectal temperature, attitude, milk production, uterine discharge, ketones) are evaluated during the first 5 to 14 days in milk (DIMs) to diagnose relevant diseases. It is well documented that 14% to 66% of healthy cows exhibit at least one temperature of 39.5 °C or greater within the first 10 DIM. Although widely adopted, data on diagnostic performance of body temperature (BT) measurement to diagnose infectious diseases (e.g., metritis, mastitis) are lacking. Therefore, the objective of this study was to identify possible factors associated with BT in postpartum dairy cows. A study was conducted on a commercial dairy farm including 251 cows. In a total of 217 cows, a vaginal temperature logger was inserted from DIM 2 to 10, whereas 34 cows did not receive a temperature logger as control. Temperature loggers measured vaginal temperature every 10 minutes. Rectal temperature was measured twice daily in all cows. On DIM 2, 5, and 10, cows underwent a clinical examination. Body temperature was influenced by various parameters. Primiparous cows had 0.2 °C higher BT than multiparous cows. Multiparous cows that calved during June and July had higher BT than those that calved in May. In primiparous cows, this effect was only evident from DIM 7 to 10. Furthermore, abnormal calving conditions (i.e., assisted calving, dead calf, retained placenta, twins) affected BT in cows. This effect was more pronounced in multiparous cows. Abnormal vaginal discharge did increase BT in primiparous and multiparous cows. Primiparous cows suffering from hyperketonemia (beta-hydroxybutyrat ≥ 1.4 mmol/L) had higher BT than those not affected. In multiparous cows, there was no association between hyperketonemia and BT. The results of this study clearly demonstrate that BT is influenced by various parameters in dairy cows. Therefore, these parameters have to be considered when interpreting measurements of BT in dairy cows. This information helps to explain the high incidence of type I and II errors when measuring BT and clearly illustrates that measures of BT should not be used as a single criterion to decide whether or not to provide antibiotic treatment to dairy cows. However, research-based test characteristics of other parameters (e.g., vaginal discharge) alone or in combination with BT are still lacking.     

Effect of days postpartum and exogenous GnRH on reproductive hormone and ovarian changes in postpartum suckled beef cows

Two experiments were conducted to determine the effect of days postpartum and exogenous gonadotropin releasing hormone (GnRH) on reproductive hormone and ovarian changes in postpartum suckled beef cows. In experiment 1, eight suckled cows were bled at .5 hour intervals for 4 hours on days 7, 14, 21 and 28 postpartum. Although mean concentrations of plasma luteinizing hormone (LH) were positively correlated with days postpartum, mean concentrations did not differ. The mean maximum change and the variance of plasma LH were low on days 7, 14, 21 and 28 postpartum. Although the number of cows with an ovarian follicle and follicular size increased with days postpartum, mean concentrations of estradiol-17beta did not change. The interval from parturition to the first detected ovarian follicle and the first postpartum estrus was 17.5 +/- 2.6 days and 36.0 +/- 2.2 days, respectively. An elevation in plasma progesterone was detected about one week prior to the first postpartum estrus in 6 of the eight cows in the absence of corpora lutea. In experiment 2, gonadotropin releasing hormone (GnRH) induced ovulation in 4 of the 8 cows treated on day 27, 28 or 29 postpartum whereas none of the 8 saline treated cows ovulated to treatment. The interval from parturition to first estrus and conception were similar for both groups (P >.10).