Social support, life events, and depression during pregnancy and the puerperium

A sample of 99 women was studied prospectively from the second trimester of pregnancy until nine weeks post partum. Depressed and nondepressed women identified at the second-trimester assessment and the postpartum assessment were compared on measures of stressful life events and social support provided by their spouses and close confidants. Nine percent of women during pregnancy and 12% of women after delivery were depressed. Women experiencing postpartum depression reported more stressful life events and less support from their spouses after delivery than the women not experiencing postpartum depression. Women experiencing depression during pregnancy reported somewhat less support from their spouses and more support from their confidants than nondepressed women. The results of the study suggest that different causes may be responsible for prepartum and postpartum depression.     

Activity of multiple sclerosis during pregnancy and puerperium

The influence of pregnancy on multiple sclerosis was studied in 338 women by determining in each trimester of pregnancy and post partum the number of relapses and the corresponding relapse rate. Eighty-five relapses occurred in association with 199 pregnancies, most (65) in the postpartum period, and a low number of relapses (2) were recorded in the last trimester of pregnancy. Comparing the average exacerbation rate of the study group with that of patients with multiple sclerosis in Israel (0.28 relapses per person per year), we found a statistically significant decrease in the third trimester (0.04) and a high increase in the first three months post partum (0.82). This pattern of remissions at the end of pregnancy and exacerbations post partum is similar to that observed in other putative autoimmune diseases.     

Serum phenytoin during pregnancy, labor and puerperium

111 pregnancies of epileptic women on phenytoin therapy were observed in a prospective study. Maternal serum phenytoin concentrations were measured monthly or bi-weekly during pregnancy, labor and puerperium. The concentration decreased towards the end of pregnancy and was lowest at delivery. In 48% of the patients the drug dosage had to be increased to combat the increased seizure frequency.     

Source of increased plasminogen activators during pregnancy and puerperium

We investigated the increase of plasminogen activators (tPA and uPA) in the plasma during pregnancy. Both tPA and uPA antigens were found to increase after the third trimester of pregnancy and high levels of PAs persisted through the first stage of labor. The tPA antigen levels rose further for the first few hours post-partum, while the level of uPA antigen returned to normal immediately following childbirth. To clarify whether the uterus and/or placenta are involved in the increased levels of plasma PAs, the levels were measured in uterine venous blood in cases of caesarean sections. During the ante-partum period, the level of uPA antigen in the uterine venous blood was higher than that in the peripheral venous blood, while there was no significant difference between the levels of tPA antigen in peripheral blood and uterine venous blood. The level of tPA antigen in the uterine venous blood rose after delivery. In contrast, the level of uPA antigen declined immediately after delivery. These results suggest that (1) the placenta is the major source of the increased uPA antigen during pregnancy, (2) entire vascular system is involved in the increased tPA antigen during pregnancy, (3) a further increase in tPA after delivery is due to the release of this enzyme from the involuting uterus.     

APC resistance and other haemostatic variables during pregnancy and puerperium

Forty-eight healthy pregnant women were studied prospectively and longitudinally. Blood sampling was performed at 10-15, 23-25, 32-34 and 38-40 weeks of gestation, within one week and at eight weeks postpartum. Classic and modified activated protein C ratio decreased as pregnancy progressed. In the third trimester 92% of the ratios measured with the classic test were above the lower reference level whereas all modified test ratios were normal. Slight activation of blood coagulation was shown with increased levels of prothrombin fragment 1+2, soluble fibrin and D-dimer. Fibrinogen, factor VIII and plasminogen activator inhibitor type I and type 2 increased. Protein S and tissue plasminogen activator activity decreased. Protein C remained unchanged. No correlation was found between the decrease in classic APC ratio and changes in factor VIII, fibrinogen, protein S, prothrombin fragment 1+2 or soluble fibrin, nor between the increase in soluble fibrin and changes in prothrombin fragment 1+2, fibrinogen and D-dimer.     

Risk factors for the increased seizure frequency during pregnancy and puerperium

Possible factors affecting the seizure frequency during pregnancy and puerperium were prospectively studied on 125 cases, paying particular attention to the drug compliance and the antiepileptic drug disposition. Of the subjects, 27% were under the poor compliance category. As the reasons for the poor compliance, anxiety about the side effects of antiepileptic drugs including teratogenecity and the harmful effects on their newborns by breast feeding were found in about half of them. In the cases with regular drug taking, 80% showed no change in the seizure frequency whereas only 16% exhibited an increase and 4% a decrease. The apparent serum clearance of phenytoin, primidone, phenobarbitone derived from primidone and valproic acid increased during pregnancy and puerperium. In some cases, the lowering of the serum level of drugs was associated with the aggravation of seizures.     

The clinical course of multiple sclerosis during pregnancy and the puerperium

Eight women with multiple sclerosis were followed up through pregnancy. Clinical conditions, T-cell subsets, and levels of immunoactive pregnancy-associated proteins were measured twice during the pregnancy and twice during the first postpartum year. None of the women's conditions worsened during pregnancy, although one woman reported a slight increase of symptoms. Six of the eight women experienced relapses within the first 7 weeks after delivery. The number and percent of CD8 suppressor T cells were lower, and the CD4 helper-CD8 suppressor T-cell ratio was higher in the pregnant patients with multiple sclerosis compared with pregnant control women throughout pregnancy and the first 6 months post partum. There was no evident relationship between these parameters and clinical disease activity. Levels of alpha-fetoprotein, alpha 2-pregnancy-associated glycoprotein, and pregnancy-associated plasma protein A, all immunosuppressive proteins associated with pregnancy, were not significantly different in pregnant patients with multiple sclerosis and pregnant controls without multiple sclerosis. The study suggested that the risk of clinical relapse after delivery may be higher than has been reported previously. Furthermore, although there were differences in suppressor T cells, they were not predictably linked to changes in clinical disease activity.     

Intracranial hemorrhage during pregnancy and puerperium: experience with fifteen cases

Intracranial hemorrhage due to arteriovenous malformation or intracranial aneurysms is a rare but grave complication of pregnancy. We analyse 15 cases. Among these, aneurysms ruptures were responsible for the bleeding in 5 instances. Arteriovenous malformation was diagnosed in other 6 patients. The maternal and fetal mortality was 20% and 33% respectively. Four aneurysm patients were operated on before delivery. We conclude that surgical management of the aneurysms is associated with lower maternal and fetal mortality than the conservative treatment. The management of angiomatous hemorrhage during pregnancy remains controversial.     

Stroke complicating pregnancy and the puerperium

Stroke complicating pregnancy and the puerperium in Taiwan and the comparison between Western and Eastern countries have not been well studied. We identified retrospectively 32 cases of stroke from 66 781 deliveries, including 21 intracranial hemorrhages and 11 cerebral infarctions from 1992 to 2004. The most common causes of intracranial hemorrhage were vascular anomaly (29%), pre-eclampsia/eclampsia (24%), undetermined (24%) and coagulopathy (19%). The most common causes of cerebral infarction were cardioembolism (36%), cerebral venous thrombosis (27%) and pre-eclampsia/eclampsia (18%). Perinatal adverse outcome included two stillbirths, nine premature deliveries and four abortions. The compiled results of previous studies and ours revealed that intracranial hemorrhage appeared to be slightly more common in Taiwan (43–69%) than in the Western countries (33–52%). The average maternal mortality rate was 17.8% (range 9–38) with 77.8% due to intracranial hemorrhage. The average incidence of stroke associated with pregnancy and the puerperium was 21.3 per 100 000 deliveries (range 8.9–67.1). Our study, different from the Western countries, showed that intracranial hemorrhage is slightly more common than cerebral infarction. Pre-eclampsia/eclampsia is an important cause of stroke, however, the possibility of cardioembolism in cerebral infarction and vascular anomaly in intracranial hemorrhage should be studied.     

Stroke in pregnancy and the puerperium

Recent studies suggest that the risk of cerebral infarction is increased during the puerperium but not during pregnancy itself. Most of the known causes of ischaemic stroke in the young have been reported during pregnancy. In most of these conditions, it is uncertain whether pregnancy is coincidental or plays a role in the occurrence of stroke. Eclampsia is the main pregnancy-specific cause, which may be associated with focal neurological deficits of sudden onset, consistent with a clinical diagnosis of stroke. However, the precise pathogenesis of these stroke-like focal deficits remains poorly understood. The two other pregnancy-specific conditions (choriocarcinoma and amniotic fluid embolism) are rarely responsible for focal cerebral ischaemia. In a significant number of patients, the cause of the stroke remains undetermined, despite an extensive aetiological investigation. Whether a hypercoagulable state and vessel wall changes associated with pregnancy may play a role in the occurrence of these otherwise unexplained ischaemic strokes remains unknown. The occurrence of cerebral venous thrombosis is clearly linked to the puerperal state, suggesting a direct role of the latter. However, cerebral venous thrombosis during pregnancy or the puerperium has been related to various aetiologies, stressing the need for an aetiological study, particularly when the thrombosis occurs during pregnancy. Pregnancy may increase the risk of subarachnoid haemorrhage, The most common cause is rupture of an arterial aneurysm. Although this is a controversial issue, the increased tendency of an aneurysm to bleed with advancing gestational age suggests that haemodynamic, hormonal or other physiological changes of pregnancy may play a role in aneurysmal rupture. The classic notion that rupture of an arterial aneurysm occurs more frequently during labour has not been confirmed. Most authors agree that surgical management after subarachnoid haemorrhage in pregnancy should be the same as that in the non-pregnant state. Data specifically devoted to intraparenchymal haemorrhage in pregnancy are scarce. Pregnancy and in particular the puerperium seem to be associated with an increased risk of intracerebral haemorrhage. The most common causes are eclampsia and ruptured vascular malformations. Whether pregnancy increases the risk of rupture of an arteriovenous malformation is controversial. Received: 30 September: 1997 Accepted: 27 October 1997     

Changes in the disposition of oxcarbazepine and its metabolites during pregnancy and the puerperium

PURPOSE: To determine potential changes in the plasma concentrations of oxcarbazepine (OXC) and its metabolites during pregnancy and puerperium. METHODS: Five women receiving OXC monotherapy were followed prospectively during pregnancy and the puerperium. Four women were enrolled in the first trimester, and one woman, 2 weeks before delivery. Steady-state concentrations of OXC, its active R-(-)- and S-(+)-monohydroxy derivatives (MHD), and the additional metabolite carbamazepine-10,11-trans-dihydrodiol (DHD) were measured at regular intervals by an enantioselective HPLC assay. RESULTS. In all samples, S-(+)-MHD was the most abundant compound in plasma and accounted almost entirely for the amount of active moiety (defined as the molar sum of OXC, R-(-)-MHD, and S-(+)-MHD) found in the circulation. The dose-normalized concentrations of active moiety decreased markedly during gestation and, in four of the five patients, increased strikingly after delivery. Plasma concentrations of S-(+)-MHD mirrored closely the levels of the active moiety. Plasma concentrations of the parent drug and other metabolites also tended to decrease during pregnancy and to increase after delivery. CONCLUSIONS: During treatment with OXC, S-(+)-MHD is by far the most abundant active compound in plasma. The concentration of this metabolite as well as the active moiety may decrease markedly during pregnancy and may increase severalfold after delivery. Because of these striking pharmacokinetic changes, the clinical response should be monitored closely in OXC-treated women throughout pregnancy and the puerperium.     

Depressed mood during pregnancy and the puerperium: clinical recognition and implications for clinical practice

Mild to moderate depression is common among women during the first 3 months postpartum. The authors studied 20 normal pregnant women in the hope of finding valid predictors of postpartum mood disorder. The subjects rated their level of emotions and various depressive symptoms at 26 and 36 weeks of pregnancy and filled out a brief questionnaire about the emotional circumstances of their pregnancy. The mood scales were repeated at 2 days and 6 weeks postpartum, along with a clinical interview. The antepartum mood scale identified women with postpartum depression and differentiated this condition from the more common, transient postpartum blues. Certain psychosocial variables also predicted postpartum distress. The authors discuss the implications of these findings, emphasizing the feasibility and necessity of routine screening for mood disturbances in prenatal and puerperal women.     

Cerebrovascular ischemic events in wind instrument players

Two cases of ischemic stroke due to carotid artery dissection occurring during wind instrument playing, probably caused by increased intrathoracic and subsequent intrapharyngeal pressure, are presented. A review of the literature revealed three similar patients with other types of cerebrovascular events, such as paradoxical cerebral embolism due to a patent foramen ovale and spinal epidural hematoma during trumpet playing.     

Platelet 3H-imipramine binding in pregnancy and the puerperium

Platelet 3H-imipramine binding was examined in a cross-sectional study of 70 Caucasian women in pregnancy and the early post-partum period, and in 23 nonpregnant women of childbearing age. Mood was also assessed in the pregnancy and post-partum sample. No significant differences in number of binding sites (Bmax) were found, but an increase in the equilibrium dissociation constant (Kd) was demonstrated at 5-7 days post-partum.