Osteopenia in pregnancy during long-term heparin treatment: a radiological study post partum

Osteopenia, sometimes with compression fractures of the spine, is a side-effect of long-term heparin treatment. The frequency is unknown. In this study, 70 women were given subcutaneous heparin as therapy for, or prophylaxis against, thromboembolism during pregnancy. All, except two, were examined by X-ray of the spine and hip first week post partum. The duration of treatment and the dosage of heparin varied. There were 12 (17%) with obvious osteopenia, including two women with multiple fractures of the spine (3%). Re-examination 6-12 months post partum showed that the changes were reversible in most cases. Another 18 women were examined about three years after heparin treatment during pregnancy. No obvious osteopenia was found among them or in a control group of 30 women examined in the first week post partum. The degree of osteopenia was not correlated with either the heparin dose or the duration of treatment. Women treated with heparin in consecutive pregnancies do not seem to have an increased risk of osteopenia.     

Calcium homeostasis in pregnancy during long-term heparin treatment.

OBJECTIVE: To investigate the effect of subcutaneous heparin treatment on calcium homeostasis in pregnancy. DESIGN: A longitudinal case-control observational study. SETTING: Department of Obstetrics and Gynaecology, Karolinska Hospital, Stockholm, Sweden. SUBJECTS: 36 pregnant women with previously verified thromboembolic complications and 23 healthy pregnant control women similar in age, parity, weight, and smoking habit. INTERVENTIONS: Thromboprophylaxis during pregnancy and 6 weeks post partum was given with subcutaneous heparin twice daily to the 36 women with a history of thromboembolic complications, 16 received an average dose of 24,500 IU/day and 20 a mean dose of 17,300 IU/day. Venous blood and urine samples were obtained every 4 weeks. MAIN OUTCOME MEASURES: Serum concentrations of total calcium, ionized calcium, calcitonin and urinary calcium. RESULTS: Women on high-dose heparin treatment showed significantly higher concentrations of total and ionized calcium and of calcitonin in serum and significantly lower concentrations of calcium in urine than did 23 normal pregnant controls. The differences were most pronounced in the third trimester. The results obtained in the low-dose heparin group were between those in the high-dose and the control groups. At 8 weeks postpartum there were no significant differences between the heparin-treated women and the controls. No significant differences were found during pregnancy in haematocrit, liver or renal function, serum levels of albumin, phosphate, magnesium, alkaline phosphatase, parathyroid hormone or urinary cyclic AMP. CONCLUSIONS: Heparin treatment during pregnancy results in changes in calcium homeostasis and a dose-dependent response is suggested.     

Urinary incontinence and weight changes during pregnancy and post partum: A pending challenge

Objectiveto analyse the association between urinary incontinence and maternal weight, and its variations in pregnancy and post partum.Designobservational study of a cohort of women from the start of pregnancy until six months post partum.SettingHospital San Pedro in La Rioja, Spain.Participants402 pregnant women without urinary incontinence at the start of pregnancy.Measurements and findingsthe dependent variable was urinary incontinence, assessed using the Urogenital Distress Inventory-Short Form questionnaire. The main independent variables were body mass index (BMI) at the first antenatal visit and six months post partum, weight gain during pregnancy, postpartum weight loss, and weight retained from the start of pregnancy to six months post partum. The association between urinary incontinence and the main independent variables was measured using Student's t-test. Three simple logistic regression models were used to assess the strength of this association, one for each of the independent variables that showed a significant association with urinary incontinence (p<0.05), and three multiple regression models that included the possible variable effect modifiers were also used. At the start of pregnancy, 20.1% of the women were overweight and 8.7% were obese. Six months post partum, 30.3% of the women were overweight and 11.4% were obese. The mean (±standard deviation) retained weight was 2 (±3.1) kg. Postpartum urinary incontinence was associated with BMI at six months post partum, postpartum weight loss and retained weight at six months post partum (p<0.05). The association of urinary incontinence with these variables was significant, and remained stable in both simple and multiple regression analyses with BMI at six months post partum [odds ratio (OR) 1.09 versus 1.08], weight loss from delivery to six months post partum (OR 0.88 versus 0.88), and retained weight from the beginning of pregnancy until six months post partum (OR 1.23 versus 1.19).Key conclusionshigh BMI and weight retention at six months post partum increase the risk of urinary incontinence, whereas postpartum weight loss decreases the risk of urinary incontinence, even if other urinary incontinence risk factors co-exist.Implications for practiceprimary care midwifes can make a major contribution towards the prevention and rehabilitation of urinary incontinence in women. It is important for the midwife and the woman to keep in contact in the first six months post partum. Individualised advice about eating and exercise habits to avoid weight retention after pregnancy may have a considerable impact on decreasing the risk of urinary incontinence.     

Fecal incontinence in pregnancy and post partum

Objective

To assess the prevalence of fecal incontinence (FI) during pregnancy and post partum, and to determine any associations with demographic and birth variables.

Methods

Secondary analysis of 240 primiparous women conducted during pregnancy and post partum. Women were asked at various time points if they had lost control over their stool or bowel movements, and if they were practicing Kegel exercises. Associations of bowel symptoms with demographic and birth data were evaluated.

Results

Most participants were white (87%), with a median age of 30 years (range, 18-42 years). Women who reported fecal incontinence at 1 year were more educated than those who did not report it. No other demographic or birth data were associated with fecal incontinence at 1 year.

Conclusions

Prevalence of FI during pregnancy and post partum is low and not linked to low-risk birth. Furthermore, when FI occurs it is often sporadic. This should be reassuring to patients and providers alike.     

Insulin-induced hypoglycaemia in diabetic women during late pregnancy and one year post partum

Insulin (0.1 IW/kg) later followed by glucose was injected intravenously in nine diabetic women in the supine position both during pregnancy and one year post partum. C-peptide was present in five subjects, indicating some residual beta-cell function. Their mean basal C-peptide level, before insulin, was twice as high in the pregnant as inthe non-pregnant state. C-peptide decreased progressively after insulin. The mean basal plasma glucose level was lower during pregnancy (4.8 mmol/l) than after it (9.6 mmol/l), but decreased to the same level (2.2 mmol/l) after insulin. The rate of fall in glucose was thus lower during pregnancy (kt = 2.54) than after (kt = 4.08), but was unrelated to the basal glucose levels. Basal levels of free fatty acids (FFA), 3-hydroxybutyrate (3-HB), cyclic AMP, and lactate were similar, while glycerol was lower during pregnancy. Insulin-induced changes in FFA, glycerol, 3-HB, cyclic AMP, and lactate were similar during and after pregnancy. Plasma amino acid concentrations were generally lower in pregnancy, significantly so only for arginine and glycine. Amino acid levels were unaffected by insulin in pregnancy, whereas leucine, isoleucine and tyrosine decreased significantly in the non-pregnancy, whereas leucine, isoleucine and tyrosine decreased significantly in the non-pregnancy, whereas leucine, isoleucine and tyrosine decreased significantly in the non-pregnancy state. We conclude that there are differences in metabolic responses to insulin in diabetic women during and after pregnancy, indicating a decreased sensitivity to insulin during pregnancy in some tissues.     

Risk factors for deep vein thrombosis and pulmonary embolism during pregnancy or post partum: a population-based, case-control study

OBJECTIVE: We sought to determine risk factors for deep vein thrombosis and pulmonary embolism during pregnancy or post partum. STUDY DESIGN: We performed a population-based case-control study. All Olmsted County, Minnesota, residents with a first lifetime deep vein thrombosis or pulmonary embolism during pregnancy or post partum from 1966 to 1990 were identified (N = 90). Where possible, a resident without deep vein thrombosis or pulmonary embolism was matched to each patient by date of the first live birth after the patient's child. The medical records of all remaining patients and all control subjects were reviewed for >25 baseline characteristics, which were tested as risk factors for deep vein thrombosis or pulmonary embolism. RESULTS: In multivariate analysis smoking (odds ratio, 2.4) and prior superficial vein thrombosis (odds ratio, 9.4) were independent risk factors for deep vein thrombosis or pulmonary thrombosis during pregnancy or post partum. CONCLUSION: Venous thromboembolism prophylaxis may be warranted for pregnant women with prior superficial vein thrombosis. Smoking cessation should be recommended, especially during pregnancy and the postpartum period.     

Zinc concentrations in maternal blood during pregnancy and post partum, in cord blood and amniotic fluid

Zinc deficiency was reported to lead to congenital malformations and abnormal fetal development, and zinc concentration in amniotic fluid has been found to be correlated with fetal birth weight. In the present study, zinc concentrations were estimated in 8 pregnant women at 15 gestational weeks and 68 pregnant women at term. Maternal serum zinc concentration in early and term pregnancy was significantly lower than that of the non-pregnant controls (mean values +/- SEM being 9.8 +/- 0.6, 9.3 +/- 0.2, and 11.5 +/- 0.3 mumol/l, respectively). Maternal serum zinc concentrations reached the non-pregnant level by one week post partum. The mean serum zinc concentration in cord blood was 14.4 (+/- 0.4) mumol/l. The zinc concentration in the amniotic fluid was very low both in early pregnancy and at term 1.1 and 0.8 mumol/l, respectively, and no correlation was found to the birth weight. Low serum zinc content in pregnant women occurs as a normal feature and congenital malformation as a consequence of disturbed zinc metabolism is probably only to be seen in instances of extreme zinc deficiency in conjunction with malnutrition.     

Common symptoms during pregnancy to predict depression and health status 14 years post partum

Objective

To examine the prospective association between symptoms commonly experienced during pregnancy and the mental and general health status of women 14 years post partum.

Methods

Data used were from the Mater-University of Queensland Study of Pregnancy, a community-based prospective birth cohort study begun in Brisbane, Australia, in 1981. Logistic regression analyses were conducted.

Results

Data were available for 5118 women. Women who experienced a higher burden of symptoms during pregnancy were at greater risk of becoming depressed and reporting poorer health status 14 years post partum. Women who experienced major problems during pregnancy were 4 times more likely to be depressed and nearly 8 times more likely to report poorer health status 14 years after the index pregnancy compared with women who experienced few problems.

Conclusions

Findings suggest that pregnant women who experience common symptoms during pregnancy are likely to experience poorer mental and self-reported general health 14 years after the pregnancy.     

Myometrial thickness during human labor and immediately post partum

OBJECTIVE: Morphologic studies suggest dramatic, asymmetric uterine growth during pregnancy that is caused by muscle cell hypertrophy. This growth is most marked at the fundus. Our objective was to evaluate sonographically the in vivo changes in myometrial thickness during active labor, second-stage labor, and after delivery. STUDY DESIGN: Abdominal ultrasound scans were performed on 52 term pregnant women to investigate the dynamic changes in myometrial thickness during the active and second stages of labor and immediately after delivery. Twenty-six women (mean +/- SEM gestational age, 39.09 +/- 0.3 weeks) were in active labor (cervical dilatation >4 cm with regular uterine contractions). An additional 26 nonlaboring women (gestational age, 39.8 +/- 0.2 weeks) provided control measurements. The myometrium was defined sonographically as the echo homogeneous layer between the serosa and the decidua. Myometrial thickness was measured at the low segment and mid anterior, fundal, and posterior uterine walls by the same observer. Myometrial thickness was also measured during uterine contractions and after artificial rupture of the amniotic membranes. All laboring women had uncomplicated labor patterns when studied and were delivered spontaneously. RESULTS: The myometrium was significantly thinner during active labor compared with nonlabor at each site studied: midanterior (mean [+/-SEM] myometrial thickness, 5.8 +/- 0.27 vs 8.83 +/- 0.51 mm; t test, P <.001), fundus (mean myometrial thickness, 6.78 +/- 0.32 vs 8.49 +/- 0.35 mm; P =.0015), and posterior (mean myometrial thickness, 6.22 +/- 0.34 vs 8.12 +/- 0.30 mm; P <.001). However, myometrial thickness did not differ among sites within the two groups. The thickness of the low segment was not affected by labor status (nonlabor, 4.68 +/- 0.48 vs labor, 4.66 +/- 0.37 mm; P =.97). Similarly, the myometrial thickness of the anterior uterine wall was unaffected by contractions (no contractions, 5.56 +/- 0.2 vs contractions, 5.68 +/- 0.22 mm; t test, P =.654). There was no change in myometrial thickness measured immediately before and after rupture of the amniotic membranes, despite a significant decrease of the amniotic fluid index. There was significant thickening of the anterior and fundal myometrium during the second stage of labor after the fetal head descended to +3 station by digital examination (anterior, 12.99 +/- 0.60 vs 5.8 +/- 0.27 mm; t test, P <.001; fundus, 10.61 +/- 1.63 vs 6.78 +/- 0.32 mm; t test, P =.04). Valsalva maneuver (pushing) during contractions did not affect myometrial thickness at the fundus (between contractions, 10.61 +/- 1.63 vs pushing, 10.76 +/- 1.95 mm; t test, P =.99). Immediately after delivery, the myometrial thickness at the placental insertion site was the thinnest. After completion of the third stage of labor, the uterine fundus remained significantly thinner than the anterior and posterior walls (fundus, 27.37 +/- 3.5 mm vs anterior, 40.94 +/- 3.5 vs posterior, 42.34 +/- 2.44; one-way analysis of variance, P =.02). CONCLUSION: There is significant and widespread thinning of the myometrium during active labor. Descent of the fetal head during the second stage of labor is associated with a significant relative thickening of the anterior and fundal myometrium. After delivery, the relationship reverses. These findings suggest the directionality of the expulsive force vectors (fundal dominance) is not determined by asymmetric myometrial growth but, rather, may be a function of increased "myometrial mass" that results from increased surface area at the fundus.     

Cardiovascular response to maximal cycle exercise during pregnancy and at two and seven months post partum

We examined the cardiovascular response at rest and during upright cycle exercise in nine women during pregnancy (25.6 +/- 3.0 weeks' gestation) and at 2 months (8.8 +/- 1.8 weeks) and 7 months (30.0 +/- 2.5 weeks) post partum. Antepartum resting cardiac output, heart rate, and stroke volume were higher, whereas the arterial-venous oxygen difference was lower than both postpartum values. The antepartum resting oxygen uptake did not differ from 2 months post partum but was higher than at 7 months post partum. Cardiac output during submaximal exercise was greater antepartum than at both postpartum tests. Submaximal antepartum oxygen uptake, heart rate, and stroke volume were generally higher, and the arterial-venous oxygen difference was lower than at 7 months post partum. The slope of the antepartum cardiac output versus oxygen uptake relationship did not differ from the value at 2 months post partum, (6.16 +/- 1.38 and 5.84 +/- 1.34, p greater than 0.05) but was higher than at 7 months post partum (5.22 +/- 0.78, p less than 0.05). There were no significant differences in maximal oxygen uptake or heart rate among the three testing periods. Maximal cardiac output and stroke volume were higher antepartum than at 2 and 7 months post partum, whereas the arterial-venous oxygen difference was lower than at 7 months post partum. There were few significant differences in resting, submaximal, or maximal measurements between the two postpartum conditions. These data suggest that the augmented cardiac response to exercise during pregnancy is reduced by 2 months post partum but that additional time may be required for a complete resolution of the cardiovascular changes induced by pregnancy.     

Sonographic assessment of symphyseal joint distention during pregnancy and post partum with special reference to pelvic pain

OBJECTIVE: To elucidate whether there is a relationship between pregnancy-related pelvic pain and degree of symphyseal laxity. METHODS: Forty-nine women were interviewed and examined and ultrasonographic measurement of symphyseal width and vertical shift was conducted at 12 and 35 weeks of pregnancy and at 5 months post partum. The patients were retrospectively classified into four groups on the basis of presence and degree of pain in late pregnancy and presence or absence of pain at follow up. RESULTS: The prevalence of pelvic pain of any degree during pregnancy was 49%, of pronounced pain 16.3% and of severe pain 6.1%. Nineteen percent had any remaining pain at 5 months post partum. The median symphyseal width at 12 and 35 weeks of pregnancy and at 5 months post partum was 3.5 mm, 4.6 mm and 2.8 mm, the median vertical shift 0.0 mm, 0.8 and 0.9 mm respectively. Those with disabling pain during pregnancy and no pain at follow up had greater symphyseal width (6.3 mm) and vertical shift (1.8 mm) at 35 weeks of pregnancy than controls; 4.5 mm (p<0.01) and 0.5 mm (p<0.01) respectively. Those with disabling pain during pregnancy and persistent pain at follow up did not differ significantly from controls in symphyseal width or shift. The most severe cases were in this group. CONCLUSION: There is a minor pregnancy-induced physiological increase in laxity of the symphyseal soft tissue. There is no evidence that the degree of symphyseal distention determines the severity of pelvic pain in pregnancy or after childbirth.     

The single unit transfusion in post partum hemorrhage: A new perspective

Every year, about 210 million women become pregnant. Postpartum hemorrhage (PPH) is one of the major complications of pregnancy, accounting for 14 million cases annually. Of these, it is estimated that around 140,000 women die, resulting in a case fatality rate of 1%. PPH is defined by WHO as a blood loss > or = 500 mls. Most instances of PPH occur suddenly and without warning even in women without any of the known risks for this condition. If women do not receive timely medical treatment, as is often the case in many parts of the world, death can occur within two hours. The chance of receiving a safe blood transfusion as part of the therapy for PPH varies enormously from country to country, depending on whether a safe blood transfusion program has been set up as a part of the national health policy. The increasing realization of the potential deleterious effects of blood transfusion, including exposure to HIV and other viral agents, has changed the practices that were previously acceptable for the transfusion of blood, as has the recent recognition of specific patients who will benefit from a single unit of blood. In countries with limited resources, where a majority of women have anemia at the onset of their pregnancies, the slightest deviation from normality during labor and/or delivery leading to excessive hemorrhage can put a women's life at risk. In these instances, the patient needs urgent resuscitation, stabilization and transfer to a nearby center. Available blood, preferably typed cross matched and screened for infections, should be given until the patient receives specific treatment. This is especially true in bled- out obstetrics patients, where one unit may make the difference between a near death state and the possibility of slow recovery and survival.     

Hormonal changes and somatopsychologic manifestations in the first trimester of pregnancy and post partum

Objective

To investigate links between psychologic distress and levels of maternal hormones and cortisol during pregnancy and post partum.

Method

The study population of 308 pregnant or recently delivered women was divided into 4 equal groups, 3 representing each pregnancy trimester and the fourth one representing the first week of the postpartum period. The women were screened for psychological distress and had blood drawn to measure serum levels of estradiol, progesterone, and total cortisol on the same day.

Results

The rates of anxiety and depression were higher in the first trimester and the postpartum groups. Depression was correlated with sharp changes in estradiol and progesterone levels; anxiety was correlated with total cortisol level; and there was a correlation between depression and anxiety.

Conclusion

Sharp changes in maternal hormone levels were correlated with depression; depression was correlated with anxiety; and anxiety was correlated with elevated cortisol levels, which may adversely affect the health of mother and offspring. Measuring maternal hormones may be a diagnostic tool to evaluate psychologic stress and associated risks.