Spontaneous recovery from hypopituitarism due to postpartum hemorrhage

A rare case is presented of a woman with spontaneous recovery from hypopituitarism following postpartum hemorrhage. One month after delivery, serum thyroid hormone, TSH, LH and FSH levels were low, and their secretion from the pituitary gland responded poorly to the TRH and LH-RH tests. Pituitary TSH response was normal 3 months after delivery. In the LH-RH test, pituitary LH and FSH response returned to normal at 2 months. Pituitary GH secretion and serum cortisol levels induced by ITT already responded normally one month postpartum. Excessive secretion of pituitary PRL was observed 3 months after delivery and improved gradually thereafter. These results indicate that the secretion of pituitary tropic hormones was sensitive to pituitary ischemia in the following order: TSH, gonadotropin, GH and ACTH. The disturbance of these hormones also persisted in the same order.     

Measurement of messenger RNA for luteinizing hormone beta-subunit and alpha-subunit during gestation and the postpartum period in ewes

Pituitary content of luteinizing hormone (LH) and mRNAs for LH beta-subunit (LH beta), alpha-subunit, prolactin, and growth hormone were measured in ewes on Days 50 and 140 of gestation and on Days 2, 13, 22, and 35 postpartum. Content of LH in dissociated anterior pituitary cells declined (P less than 0.05) between Days 50 and 140 of gestation and remained low at 2 days postpartum. By 22 days postpartum, pituitary concentrations of LH were comparable to concentrations in normally cycling ewes. During gestation concentrations of mRNA for LH beta and alpha-subunit paralleled changes in cellular content of LH, reaching minimal levels on Day 140. By Day 2 postpartum, pituitary concentrations of mRNAs for LH beta and alpha-subunit began to increase; they reached maximum levels by Day 13 postpartum. There appeared to be a gradual linear increase in mRNA for prolactin through gestation and the postpartum period. No changes in mRNA for growth hormone were noted during the prepartum or postpartum periods. These data suggest that the decline in pituitary concentrations of LH during gestation is due to a decrease in cellular mRNA for LH beta and alpha-subunit. The increase in mRNA for LH beta and alpha-subunit appears to precede an increase in cellular content of LH in the postpartum ewe by several days.     

Postpartum depression: Etiology,treatment and consequences for maternal care

This article is part of a Special Issue “Parental Care”. Pregnancy and postpartum are associated with dramatic alterations in steroid and peptide hormones which alter the mothers' hypothalamic pituitary adrenal (HPA) and hypothalamic pituitary gonadal (HPG) axes. Dysregulations in these endocrine axes are related to mood disorders and as such it should not come as a major surprise that pregnancy and the postpartum period can have profound effects on maternal mood. Indeed, pregnancy and postpartum are associated with an increased risk for developing depressive symptoms in women. Postpartum depression affects approximately 10–15% of women and impairs mother–infant interactions that in turn are important for child development. Maternal attachment, sensitivity and parenting style are essential for a healthy maturation of an infant's social, cognitive and behavioral skills and depressed mothers often display less attachment, sensitivity and more harsh or disrupted parenting behaviors, which may contribute to reports of adverse child outcomes in children of depressed mothers. Here we review, in honor of the “father of motherhood”, Jay Rosenblatt, the literature on postnatal depression in the mother and its effect on mother–infant interactions. We will cover clinical and pre-clinical findings highlighting putative neurobiological mechanisms underlying postpartum depression and how they relate to maternal behaviors and infant outcome. We also review animal models that investigate the neurobiology of maternal mood and disrupted maternal care. In particular, we discuss the implications of endogenous and exogenous manipulations of glucocorticoids on maternal care and mood. Lastly we discuss interventions during gestation and postpartum that may improve maternal symptoms and behavior and thus may alter developmental outcome of the offspring.     

A Cross-Sectional Analytic Study of Postpartum Health Care Service Utilization in the Philippines

Background

The maternal mortality ratio in the Philippines remains high; thus, it will be difficult to achieve the Millennium Development Goals 5 by 2015. Approximately two-thirds of all maternal deaths occur during the postpartum period. Therefore, we conducted the present study to examine the current state of postpartum health care service utilization in the Philippines, and identify challenges to accessing postpartum care.

Methods

A questionnaire and knowledge test were distributed to postpartum women in the Philippines. The questionnaire collected demographical characteristics and information about their utilization of health care services during pregnancy and the postpartum period. The knowledge test consisted of 11 questions regarding 6 topics related to possible physical and mental symptoms after delivery. Sixty-four questionnaires and knowledge tests were analyzed.

Results

The mean time of first postpartum health care visit was 5.1±5.2 days after delivery. Postpartum utilization of health care services was significantly correlated with delivery location (P<0.01). Women who delivered at home had a lower rate of postpartum health care service utilization than women who delivered at medical facilities. The majority of participants scored low on the knowledge test.

Conclusion

We found inadequate postpartum health care service utilization, especially for women who delivered at home. Our results also suggest that postpartum women lack knowledge about postpartum health concerns. In the Philippines, Barangay health workers may play a role in educating postpartum women regarding health care service utilization to improve their knowledge of possible concerns and their overall utilization of health care services.     

Evaluation of hypothalamic-pituitary function in a combination of tests with four hypothalamic releasing hormones and L-dopa in normal subjects and in patients with hypothalamic and/or pituitary disorders

Hypothalamic-pituitary function was evaluated in a combination of tests with four hypothalamic releasing hormones (4RHs) and L-dopa in normal subjects and in patients with hypothalamic and/or pituitary disorders. Plasma concentrations of anterior pituitary hormones (GH, ACTH, TSH, PRL, LH and FSH) were measured before and after simultaneous iv administration of GHRH, CRH, TRH and LHRH. In addition, changes in the plasma levels of GHRH and GH were investigated before and after oral administration of L-dopa. Normal subjects showed appreciable responses to both tests. In five patients with hypothalamic disorders, the response of plasma anterior pituitary hormones varied, but plasma GHRH and GH did not respond to L-dopa. Patients with idiopathic and postpartum hypopituitarism showed low response to 4RHs or none at all, but L-dopa evoked a normal GHRH response in 2 of the 4 cases having no GH response. In the patients with hypopituitarism due to resection of a pituitary tumor, the response of anterior pituitary hormones to 4RHs was low, and L-dopa administration induced a normal GHRH and low GH response in 5 out of the 7 cases. After 4RHs administration, the patients with ACTH deficiency syndrome showed different patterns of impaired ACTH secretion, and isolated, combined or limited ACTH reserve. Seven patients with anorexia nervosa showed exaggerated GH, delayed TSH and FSH, low ACTH and LH, that is, normal PRL response to 4RHs, but no response of plasma GHRH or GH to L-dopa, suggesting the presence of hypothalamic dysfunction. These results indicate that the combination of the 4RHs test and L-dopa test is a simple and useful means for evaluating hypothalamic-pituitary function by measuring the response of plasma GHRH and six anterior pituitary hormones in the patients with endocrine disorders.     

Postpartum thyroiditis: current views on unappreciated disease

Postpartum thyroiditis is a form of autoimmune thyroiditis developing during the first 12 months postpartum as a consequence of the immunologic flare following the immune suppression of pregnancy. This disease, found in 5-10% of women in a general population and even more frequently in patients suffering from other autoimmune disorders, may re-occur in about 70% of women after a subsequent pregnancy. Postpartum thyroiditis is strongly associated with antithyroid peroxidase antibodies. Patients may present with symptoms of either thyrotoxicosis or hypothyroidism which may be transient or, in some (20-30%) cases of hypothyroidism, permanent in nature. A thyrotoxic phase of postpartum thyroiditis is usually brief and often unnoticed before a more long-lasting hypothyroid phase occurs. The diagnosis of postpartum thyroiditis is based on the observation of abnormal thyroid function tests in a postpartum antithyroid peroxidase- positive woman. In this paper, we discuss the etiopathogenesis, clinical picture, diagnosis, prognosis and treatment of postpartum thyroiditis and provide the reader with some practical guidance concerning dealing with a patient suffering from this disorder.     

Relapse to smoking and postpartum weight retention among women who quit smoking during pregnancy

Postpartum weight retention contributes to obesity risk in women. Given that most women who quit smoking as a result of pregnancy will resume smoking within 6 months postpartum and that there is a robust association between smoking and weight, we sought to evaluate postpartum weight retention as a function of postpartum smoking status among women who had quit smoking during pregnancy. Women (N = 183) with biochemically confirmed cigarette abstinence at the end of pregnancy were recruited between February 2003 and November 2006. Women self-reported demographic information and weight before pregnancy. Smoking status and weight were documented at the end of pregnancy and at 6, 12, and 24 weeks postpartum. Breastfeeding was reported at 6 weeks postpartum. Differences in weight retention by relapse status at each assessment were evaluated. To examine weight retention in the presence of conceptually relevant covariates, mixed models with log-transformed weight data were used. At 24 weeks postpartum, 34.6% of women remained abstinent. Women who remained abstinent throughout the 24-week period retained 4.7 ± 2.1 kg more than did women who had relapsed by 6 weeks postpartum, P = 0.03. This difference in postpartum weight retention was significant after controlling for relevant covariates (age, race, breastfeeding, and pregravid BMI). Resumption of smoking within the first 6 weeks following childbirth is associated with decreased postpartum weight retention, even after controlling for breastfeeding and pregravid weight. Interventions to sustain smoking abstinence postpartum might be enhanced by components designed to minimize weight retention.     

The influence of the frequency of nursing and of previous lactation experience on serum prolactin in lactating mothers

Serum prolactin levels were measured for 97 women from Zaire for 22 months postpartum. These 97 women were divided into 3 groups according to how frequently they breast-fed their children. These results were compared with the prolactin levels of 25 nonlactating, nonpregnant women. The prolactin levels increased with the frequency of breast-feeding. The postpartum decrease in serum prolactin is quicker among women who breast-feed less frequently; the serum prolactin levels returned to normal ranges within 6 months postpartum among women who breast-fed their children 1-3 times/day. No correlation could be found between previous breast-feeding or the parity of women and prolactin levels during subsequent pregnancies.     

Physiological Reduction in Left Ventricular Contractile Function in Healthy Postpartum Women: Potential Overlap with Peripartum Cardiomyopathy

Aims

Peripartum cardiomyopathy is a potentially life-threatening cause of heart failure, commoner in Afro-Caribbean than Caucasian women. Its diagnosis can be challenging due to physiological changes in cardiac function that also occur in healthy women during the early postpartum period. This study aimed to (i) establish the overlap between normal cardiac physiology in the immediate postpartum period and pathological changes in peripartum cardiomyopathy ii) identify any ethnicity-specific changes in cardiac function and cardiac biomarkers in healthy postpartum women.

Methods and Results

We conducted a cross-sectional study of 58 healthy postpartum women within 48 hours of delivery and 18 matched non-pregnant controls. Participants underwent cardiac assessment by echocardiography and strain analysis, including 3D echocardiography in 40 postpartum women. Results were compared with 12 retrospectively studied peripartum cardiomyopathy patients. Healthy postpartum women had significantly higher left ventricular volumes and mass, and lower ejection fraction and global longitudinal strain than non-pregnant controls. These parameters were significantly more impaired in peripartum cardiomyopathy patients but with overlapping ranges of values. Healthy postpartum women had higher levels of adrenomedullin, placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt1) compared to controls. The postpartum state, adrenomedullin, sFlt1 and the sFlt1:PlGF ratio were independent predictors of LV remodelling and function in healthy postpartum women.

Conclusion

Healthy postpartum women demonstrate several echocardiographic indicators of left ventricular remodelling and reduced function, which are associated with altered levels of angiogenic and cardiac biomarkers.     

Emotion Reactivity Is Increased 4-6 Weeks Postpartum in Healthy Women: A Longitudinal fMRI Study

Marked endocrine alterations occur after delivery. Most women cope well with these changes, but the postpartum period is associated with an increased risk of depressive episodes. Previous studies of emotion processing have focused on maternal–infant bonding or postpartum depression (PPD), and longitudinal studies of the neural correlates of emotion processing throughout the postpartum period in healthy women are lacking. In this study, 13 women, without signs of post partum depression, underwent fMRI with an emotional face matching task and completed the MADRS-S, STAI-S, and EPDS within 48 h (early postpartum) and 4–6 weeks after delivery (late postpartum). Also, data from a previous study including 15 naturally cycling controls assessed in the luteal and follicular phase of the menstrual cycle was used. Women had lower reactivity in insula, middle frontal gyrus (MFG), and inferior frontal gyrus (IFG) in the early as compared to the late postpartum assessment. Insular reactivity was positively correlated with anxiety in the early postpartum period and with depressive symptoms late postpartum. Reactivity in insula and IFG were greater in postpartum women than in non-pregnant control subjects. Brain reactivity was not correlated with serum estradiol or progesterone levels. Increased reactivity in the insula, IFG, and MFG may reflect normal postpartum adaptation, but correlation with self-rated symptoms of depression and anxiety in these otherwise healthy postpartum women, may also suggest that these changes place susceptible women at increased risk of PPD. These findings contribute to our understanding of the neurobiological aspects of the postpartum period, which might shed light on the mechanisms underlying affective puerperal disorders, such as PPD.     

Increased risk of postpartum depressive symptoms is associated with slower normalization after pregnancy of the functional docosahexaenoic acid status

Observational studies suggest an association between a low docosahexaenoic acid (DHA, 22:6n-3) status after pregnancy and the occurrence of postpartum depression. However, a comparison of the actual biochemical plasma DHA status among women with and without postpartum depression has not been reported yet. The contents of DHA and of its status indicator n-6 docosapentaenoic acid (n-6DPA, 22:5n-6) were measured in the plasma phospholipids of 112 women at delivery and 32 weeks postpartum. At this latter time point, the Edinburgh Postnatal Depression Scale (EPDS) questionnaire was completed to measure postpartum depression retrospectively. The EPDS cutoff score of 10 was used to define 'possibly depressed' (EPDS score > or =10) and non-depressed women (EPDS score <10). Odds ratios (OR) were calculated using a multiple logistic regression analysis with the EPDS cutoff score as dependent and fatty acid concentrations and ratio's as explanatory variables, while controlling for different covariables. The results demonstrated that the postpartum increase of the functional DHA status, expressed as the ratio DHA/n-6DPA, was significantly lower in the 'possibly depressed' group compared to the non-depressed group (2.34+/-5.56 versus 4.86+/-5.41, respectively; OR=0.88, P=0.03). Lactating women were not more predisposed than non-lactating women were to develop depressive symptoms. From this observation it seems that the availability of DHA in the postpartum period is less in women developing depressive symptoms. Although further studies are needed for confirmation, increasing the dietary DHA intake during pregnancy and postpartum, seems prudent.     

Effects of the intensity of the suckling stimulus and ovarian steroids on pituitary gonadotropin-releasing hormone receptors during lactation

These studies examined whether the decrease in pituitary responsiveness to gonadotropin-releasing hormone (GnRH) observed during lactation in the rat results from a change in pituitary GnRH receptors. GnRH binding capacity was determined by saturation analysis using D-Ala6 as both ligand and tracer. During the estrous cycle, the number of GnRH binding sites increased from 199 +/- 38 fmol/mg protein on estrus to 527 +/- 31 fmol/mg protein on the morning of proestrus, whereas there was no change in receptor affinity (Ka, 6-10 X 10(9) M-1), During lactation, females nursing 8 pups on Days 5 or 10 postpartum had 50% fewer GnRH receptors (109-120 fmol/mg protein) than observed during estrus or diestrus 1 (199-242 fmol/mg protein) although receptor affinity was similar among all the groups. No deficits in pituitary GnRH receptors were observed in females nursing 2 pups on Day 10 postpartum. Removal of the 8-pup suckling stimulus for 24 or 48 h resulted in a dramatic increase in GnRH receptor capacity by 24 h from 120 +/- 16 to 355 +/- 39 fmol/mg protein. The rise in GnRH receptors after pup removal was accompanied by an increase in serum luteinizing hormone (LH) and estradiol concentrations. To assess the role of ovarian steroids in determining GnRH receptor capacity during lactation, females were ovariectomized (OVX) on Day 2 postpartum. Suckling of a large litter (8 pups) completely blocked the postcastration rise in serum LH and in pituitary GnRH receptors on Day 10 postpartum (OVX+ 8, 77 +/- 12 fmol/mg protein; OVX+ 0, 442 +/- 38 fmol/mg protein).(ABSTRACT TRUNCATED AT 250 WORDS)     

Resumption of menstruation among urban post-partum women in Bangladesh.

To investigate the return of menstruation among postpartum women in Dacca, a random sample of 360 women (1-12 months postpartum) was selected from 4 Dacca hospitals for a cross-sectional study; another random sample of 200 women ( 1 month postpartum at time of interview) was selected from the same hospitals for prospective follow up. Many of the women were from rural areas who left the city after delivering their babies; most were under 25 years old at the time of interview. Results of the cross sectional study showed that 63% started menstruating by the 6th postpartum month; 10% were still amenorrhoeic by the 12th postpartum month; 46% were breastfeeding their infants by the 4th month; 90% resumed sexual relations, and 48% were using contraceptives, by the 6th month. Results of the prospective study showed that slightly more than half of the women started menstruating by the end of the 5th postpartum month; almost half stopped breastfeeding by the 5th month, 88.8% were having sexual relations with their husbands, and about 50.5% were on some form of birth control. The findings suggest a much shorter duration of lactational amenorrhea than has been claimed for a rural area of Bangladesh; they also suggest that urban women start menstruating earlier because of their primary reliance on supplementary feeding. The contraceptive effectiveness, as well as health benefits to infants, of prolonged and intensive lactation should be promoted to urban mothers.     

High Prepregnancy BMI Increases the Risk of Postpartum Anemia

Objective: To assess the independent effect of prepregnancy BMI on the risk of postpartum anemia. Research Methods and Procedures: Pregnant women from North Carolina who enrolled in the Iron Supplementation Study at their first prenatal visit at <20 weeks gestation and who delivered a live infant were followed to the postpartum visit (n = 439). BMI had a curvilinear relation in the logit of postpartum anemia; therefore, a restricted quadratic spline with three knots at the inflection points was used to specify BMI. Multiple log binomial regression was used to quantify the relation between prepregnancy BMI and postpartum anemia after adjusting for maternal ethnicity/race, education, smoking, initial hemoglobin concentration, and prenatal iron supplementation. Results: Prevalence of postpartum anemia was 19.1%. After adjusting for confounders, we found that risk of postpartum anemia was similar for women with BMI values from 17 to 24 compared with women with a BMI of 20. Adjusted relative risk increased as BMI increased from 24 to 38. Women with a BMI of 28 had ～1.8 times the postpartum anemia risk of a woman with a BMI of 20 (95% confidence interval 1.3, 2.5), and obese women with a BMI of 36 had ～2.8 times the risk (95% confidence interval 1.7, 4.7). Discussion: These data suggest that high prepregnancy BMI substantially increases the risk of postpartum anemia. Postpartum anemia screening and iron supplementation of overweight and obese women may be warranted.     

Temporary peripartal impairment in memory and attention and its possible relation to oxytocin concentration

The aim of the present study was to investigate peripartal performance on cognitive tests and its possible relationship with plasma oxytocin concentrations. Twenty women (cases) were tested on five experimental occasions, the first toward the end of pregnancy and the last 12 months postpartum. On each experimental occasion performance on cognitive tests of memory and attention was recorded and oxytocin concentrations were simultaneously assayed in plasma-samples. Twenty non-pregnant women (controls) were investigated at similar intervals. Cases were found to have improved their performance on some cognitive tests significantly more than controls when results at 6 and 12 months after delivery were compared with those from the end of pregnancy and up to three months after partus. This observation strongly suggests impairment in cognitive performance during the peripartal period. Cases had significantly higher oxytocin concentrations than controls in plasma samples up to three months post partum. No correlation was, however, found between cognitive test results and levels of oxytocin concentration.     

The incidence of the pituitary autoantibodies in Graves' disease

INTRODUCTION: It is known that in the sera of patients with Graves, Addison and other autoimmune endocrine diseases we can detect autoantibodies against pituitary antigens. The aim of the study was evaluation of pituitary autoantibodies in Graves' disease patients using immunoblotting methods. MATERIAL AND METHODS: Studies were performed in 32 Graves' disease patients, 25 women (age range: 31-67 yrs, median: 49.9 +/- 9.4) and 7 men (age range: 41-58 yrs, median: 51.0 +/- 7.1). All patients presented signs and symptoms typical of thyrotoxicosis. The diagnosis was confirmed by laboratory tests (TSH, fT(3), fT(4), TSH-R antibodies). Sera of control subjects were obtained from 10 healthy blood donors, 7 women, 3 men (age range 21-45 yrs, median: 30.6 +/- 7.1). Incidence of pituitary autoantibodies was assessed by polyacrylamide electrophoresis gel and western-blotting. Pituitary microsomes were obtained from human pituitary tissues by ultracentrifugation and solubilisation in 1% desoxycholic acid. RESULTS: In 23 sera from 32 we detected autoantibodies against pituitary microsomal antigens. 16 sera were reacting with 55 kDa antigen, 10 sera with 67 kDa, 6 sera with 60 kDa, 5 sera with 52 kDa and 4 sera with 105 kDa. It is important to note that 6 sera were reacting with 57 and 55 kDa, and 5 sera with 55, 60 and 67 kDa. CONCLUSIONS: In sera of Graves' disease patients autoantibodies against pituitary microsomal antigens can be frequently detected. The most frequent are antibodies against 55, 60 and 67 kDa antigens.     

Effects of Progestogen Oral Contraception with Norethisterone on Blood Clotting and Platelets

The effects on clotting tests and platelet function of six months'' continuous administration of the 19-norsteroid, progestogen-only contraceptive, norethisterone, have been studied in four groups of women. In a group of women who have not previously taken oral contraceptive no acceleration of clotting or platelet factors was found, but in contrast a tendency to reduced coagulability was observed. Women who had previously been taking combined oestrogen-progestogen preparations showed reduced clotting and platelet parameters when norethisterone was substituted. No changes in clotting or platelets were found in women who changed from 17-acetoxysteroid progestogen chloramadinone acetate or in a group of women started postpartum.     

Growth hormone-releasing factor (GRF) stimulation test in the diagnosis of pituitary adenomas

The studies aimed at evaluation of pituitary reserve of growth hormone following stimulation with GRF have been carried out in a group of 33 patients (11 women and 22 men, of age between 25 and 62 years) with pituitary tumors. The studied material included cases with pituitary adenoma characterized by excessive secretion of growth hormone (somatotropinoma), prolactin (prolactinoma) or alpha subunits of glycoprotein hormones (alphoma), and those with hormonally inactive adenoma. The GRF stimulation tests were carried out in hospitalized patients after overnight fast between 8.00 and 10.00 a.m. Blood samples for hormonal determinations were taken before the test, and after 15, 30, 60, 90 and 120 minutes following intravenous administration of 100 micrograms of GRF 1-29. Besides growth hormone, also the blood serum concentrations of other pituitary hormones were determined in the patients studied, both in the basal state and during the dynamic tests. In patients with acromegaly the results of the determinations of growth hormone following stimulation with GRF showed considerable individual variability. In 5 cases there was an increase in blood serum growth hormone concentration. No response to GRF was noted in the remaining 8 cases. In adenoma cases of prolactinoma type, growth hormone concentration began to rise already at the 15-th minute of the test in most cases. In three cases of prolactinoma associated with acromegaly no response to GRF was observed. The cases of alphoma-type adenoma were usually characterized by the secretion of pituitary hormones other than growth hormone.(ABSTRACT TRUNCATED AT 250 WORDS)     

Postpartum thyroid dysfunction in Mid Glamorgan

A high prevalence of postpartum thyroid dysfunction has been reported in several countries, but there have been no systematic studies of its prevalence in Britain. Among a group of 901 consecutive, unselected pregnant women thyroid autoantibodies were detected in 117 (13%) at booking. The clinical course of postpartum thyroid dysfunction, factors associated with its development, and its likely prevalence were defined in 100 of these women with thyroid antibodies and 120 women with no such antibodies who were matched for age. None of the women had a history of autoimmune thyroid disease. Normal reference ranges for thyroid function during pregnancy and post partum were established in the 120 women negative for thyroid antibodies. On the basis of these observations postpartum thyroid dysfunction was observed in 49 (22%) of the 220 women studied, and the prevalence in the total group of 901 women was estimated to be 16·7%. Thyroid dysfunction, mainly occurring in the first six months post partum, was usually transient and included both destruction induced hyperthyroidism and hypothyroidism. The development of the syndrome was significantly related to smoking more than 20 cigarettes a day and the presence of thyroid microsomal autoantibodies at booking. Of the 16 women with a family history of thyroid disease in whom thyroid microsomal autoantibody activity was detectable at booking, 11 developed thyroid dysfunction. Age, parity, presence of goitre at presentation, duration of breast feeding, and the sex and birth weight of the infant were not associated with the development of postpartum thyroid dysfunction.The mood changes experienced by women post partum may in part be associated with altered thyroid function during this time.     

Impact of round-the-clock, rapid oral fluid HIV testing of women in labor in rural India

Background

Testing pregnant women for HIV at the time of labor and delivery is the last opportunity for prevention of mother-to-child HIV transmission (PMTCT) measures, particularly in settings where women do not receive adequate antenatal care. However, HIV testing and counseling of pregnant women in labor is a challenge, especially in resource-constrained settings. In India, many rural women present for delivery without any prior antenatal care. Those who do get antenatal care are not always tested for HIV, because of deficiencies in the provision of HIV testing and counseling services. In this context, we investigated the impact of introducing round-the-clock, rapid, point-of-care HIV testing and counseling in a busy labor ward at a tertiary care hospital in rural India.

Methods and Findings

After they provided written informed consent, women admitted to the labor ward of a rural teaching hospital in India were offered two rapid tests on oral fluid and finger-stick specimens (OraQuick Rapid HIV-1/HIV-2 tests, OraSure Technologies). Simultaneously, venous blood was drawn for conventional HIV ELISA testing. Western blot tests were performed for confirmatory testing if women were positive by both rapid tests and dual ELISA, or where test results were discordant. Round-the-clock (24 h, 7 d/wk) abbreviated prepartum and extended postpartum counseling sessions were offered as part of the testing strategy. HIV-positive women were administered PMTCT interventions. Of 1,252 eligible women (age range 18 y to 38 y) approached for consent over a 9 mo period in 2006, 1,222 (98%) accepted HIV testing in the labor ward. Of these, 1,003 (82%) women presented with either no reports or incomplete reports of prior HIV testing results at the time of admission to the labor ward. Of 1,222 women, 15 were diagnosed as HIV-positive (on the basis of two rapid tests, dual ELISA and Western blot), yielding a seroprevalence of 1.23% (95% confidence interval [CI] 0.61%–1.8%). Of the 15 HIV test–positive women, four (27%) had presented with reported HIV status, and 11 (73%) new cases of HIV infection were detected due to rapid testing in the labor room. Thus, 11 HIV-positive women received PMTCT interventions on account of round-the-clock rapid HIV testing and counseling in the labor room. While both OraQuick tests (oral and finger-stick) were 100% specific, one false-negative result was documented (with both oral fluid and finger-stick specimens). Of the 15 HIV-infected women who delivered, 13 infants were HIV seronegative at birth and at 1 and 4 mo after delivery; two HIV-positive infants died within a month of delivery.

Conclusions

In a busy rural labor ward setting in India, we demonstrated that it is feasible to introduce a program of round-the-clock rapid HIV testing, including prepartum and extended postpartum counseling sessions. Our data suggest that the availability of round-the-clock rapid HIV testing resulted in successful documentation of HIV serostatus in a large proportion (82%) of rural women who were unaware of their HIV status when admitted to the labor room. In addition, 11 (73%) of a total of 15 HIV-positive women received PMTCT interventions because of round-the-clock rapid testing in the labor ward. These findings are relevant for PMTCT programs in developing countries.