Risk factors in pregnancy for post-traumatic stress and depression after childbirth.

OBJECTIVE: The objective of this study was to find risk factors in pregnancy for post-traumatic stress and depression 1 month after childbirth. Furthermore, the relation between post-traumatic stress and depression was explored. DESIGN: A prospective longitudinal study. SETTING: Pregnant women in Linköping and Kalmar, Sweden. POPULATION: A total of 1224 women were assessed in pregnancy, week 12-20 and 32, as well as 1 month postpartum. METHODS: Post-traumatic stress and depression after delivery were assessed 1 month postpartum. Potential risk factors were assessed in early and late pregnancy. Variables measured during pregnancy were trait anxiety, depression, fear of childbirth, childbirth-related traumatic stress, stress coping capacity, social support, parity, educational level, age, gestation week, parity, educational level, civil status, previous psychological/psychiatric counselling, and previous experience of any traumatic events. Delivery mode was assessed from the medical records. MAIN OUTCOME MEASURES: Prevalence of post-traumatic stress (criteria A, B, C, D, E, and F according to DSM-IV) and depression (Beck's depression inventory). RESULTS: One month postpartum, 12 (1.3%) women had post-traumatic stress (met symptom criteria B, C, and D for post-traumatic stress disorder according to Diagnostic and statistical manual of mental disorders, 4th edition [DSM-IV]). The most important risk factors in pregnancy were depression in early pregnancy (OR=16.3), severe fear of childbirth (OR=6.2), and 'pre'-traumatic stress (in view of the forthcoming delivery) in late pregnancy (OR=12.5). The prevalence of depression was 5.6%. Post-traumatic stress and depression were positively related 1 month postpartum and were predicted by mainly the same factors. CONCLUSIONS: Risk factors for post-traumatic stress and depression after childbirth can be assessed in early pregnancy. Post-traumatic stress and depression also seem to share the same underlying vulnerability factors.

Risk factors for rupture of the anal sphincter.

OBJECTIVE: To evaluate risk factors for rupture of the anal sphincter during vaginal delivery. MATERIAL AND METHODS: All 292 parturients with rupture of the anal sphincter in four neighbouring central hospitals in southern Sweden between 1988 and 1990 were identified retrospectively. For each case a control was selected, the sole matching criterion being that the control woman was the next to give birth vaginally in the same unit as the case. Only singleton deliveries were included. For comparison of risk factors among cases and controls, McNemar's test was used for bivariate testing; multiple regression analysis was restricted to those variables found to be significant in the bivariate analysis. Odds ratios (OR) were calculated with 95% confidence limits (CL). RESULTS: In all, 292 of 22,653 deliveries (1.3%) had a rupture of the anal sphincter. Of a total of 14 independent variables explored, 8 were found to be significantly associated with rupture of the anal sphincter in the bivariate testing. In the following multivariate analysis, three variables remained significantly associated with rupture of the anal sphincter: birthweight > or = 4000 g (OR 2.6; CL 1.7, 3.9), primiparity (OR 2.2; CL 1.5, 3.3) and episiotomy (OR 1.7; CL 1.1, 2.6). CONCLUSION: Episiotomy appears to be significantly associated with rupture of the anal sphincter. In contrast to primiparity and birthweight, the incidence of episiotomy during vaginal delivery may easily be reduced. However, only a prospective, controlled study will disclose the true negative or positive effects of episiotomy.

Genital tract infections associated with the intrauterine contraceptive device can be reduced by inserting the threads into the uterine cavity.

OBJECTIVE: To study the influence of the position of the threads of an intrauterine contraceptive device (IUCD) on the development of genital tract infection. DESIGN: A multicentre randomized controlled trial. SUBJECTS: Women requesting an IUCD. INTERVENTIONS: The women were randomized to be fitted with an IUCD either with the threads contained in the uterine cavity (threads-up group) (n = 208) or passing through the cervix to the vagina in the usual way (threads-down group) (n = 237). Multiple centre study with follow-up at three months, 1 and 2 years. At the final visit 'missing' threads were retrieved using a disposable instrument (Retrievette). MAIN OUTCOME MEASURES: The occurrence of infection in the lower or upper genital tract. RESULTS: 63 women in the threads-up group and 78 in the threads-down groups dropped out. Previous gynaecological infection was reported by 21 and 48 women in the threads-up and threads-down group, respectively (odds ratio 0.44, 95% CI 0.24 to 0.79), 21 and 53 subjects had signs of infection at gynaecological examination (odds ratio 0.39, 95% CI 0.21 to 0.69) and a wet-smear was pathological in 33 and 79 (odds ratio 0.38, 95% CI 0.23 to 0.61). In the threads-up group the vaginal pH was also lower at the final check up after 2 years. Spontaneous descent of the threads occurred in 11% of the threads-up group and in six women in the threads-down group the threads were in the cervix. In 93 women the threads were easily retrieved by means of the Retrievette, four women insisted on the threads remaining in the uterus and in 18 thread removal was performed under local or general anaesthesia. CONCLUSIONS: Infectious complications in women using an IUCD are more frequent if the threads lead from the uterine cavity to the vagina. This problem can be reduced by inserting the threads so that they remain entirely within the uterine cavity, a feasible procedure now that an effective instrument for IUCD thread retrieval is available.

PIP: This study examined the influence of the position of the threads of an IUD on the development of a genital tract infection. Women who requested and IUD were part of this multicenter randomized controlled trial. These women were randomized to be fitted with an IUD either with the threads contained in the uterine cavity (threads-up group; n=208) or passing through the cervix to the vagina in the usual way (threads-down group; n=237). Followup occurred at 2 months, 1 year, and 2 years. At the final visit, missing threads were retrieved using a disposable instrument (Retrievette). 63 women in the threads-up group and 78 in the threads-down group dropped out and previous gynecological infection was reported by 21 and 48 women in the threads-up and threads-down group, respectively (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.24-0.79), 21 and 53 subjects had signs of infection at gynecological examination (OR 0.39, 95% CI 0.21-0.69), and a wet-smear was pathological in 33 and 79 (OR 0.38, 95% CI 0.23-0.61). In the threads-up group, the vaginal pH was also lower at the final checkup after 2 years. Spontaneous descent of the threads occurred in 11% of the threads-up group and in 6 from the other group, threads were in the cervix. In 93 women, the threads were easily retrieved by means of the Retrievette, 4 women insisted on the threads remaining in the uterus and in 18, thread removal was performed under local or general anesthesia. Infectious complications in women using and IUD are more frequent if the threads lead from the uterine cavity to the vagina. This problem can be reduced by inserting the threads so that they remain entirely within the uterine cavity, a feasible procedure now that an effective instrument for IUD thread retrieval is available.

Local mechanical effects and humoral factors evoke degeneration of guinea pig uterine innervation.

Small porcelain pellets were inserted into one of the uterine horns of virgin guinea pigs. Mating caused pregnancies only in contralateral, non-pellet-containing uterine horns. The number and morphology of uterine nerve structures was studied immunohistochemically. In pellet-surrounding tissues of virgin animals the number of nerves was reduced and remaining nerve structures displayed signs of degeneration. This nerve reduction was further advanced in early to mid-pregnancy when almost no nerve structures could be detected. Myometrial strips were transplanted to the anterior eye chamber and became reinnervated by adrenergic nerves. The pattern and structure of the adrenergic reinnervation did not differ between strips taken from virgin animals, untreated or following chemical sympathectomy, or taken from primiparous animals following pregnancy induced sympathectomy. The adrenergic reinnervation of transplants from virgin animals was not affected by pregnancy of the recipient animal. It is suggested that the uterine innervation can be influenced by local, mechanically-induced effects, which during pregnancy co-operate with conceptus-related humoral factors to cause an almost total uterine nerve degeneration. The ability of uterine adrenergic reinnervation is probably not significantly influenced by local environmental tissue factor(s), but is related rather to extent of nerve damage.

A study of pregnancy outcome in a small area around a chemical factory and a chemical dump.

Pregnancy outcome was studied in three parishes situated around a chemical factory from which air and water pollution was considered to have occurred. Data on health variables were mainly obtained from registries supplemented with hospital record information. No definite reproductive hazards could be demonstrated but an unusually high perinatal death rate among twins born in the area was noticed. The paper discusses principles involved in the design of a study of this type.

Inhibition of lactation by cyclofenil and bromocriptine.

In a double blind controlled study of the inhibition of lactation 13 women received 300 mg of cyclofenil and 11 women 2.5 mg of bromocriptine twice daily for 14 days. Lactation was effectively inhibited by both drugs, but with bromocriptine there was a significantly higher frequency of relapse. The plasma concentration of prolactin, which decreased rapidly with bromocriptine, returned to the pretreatment level the day after drug treatment stopped, but with cyclofenil it remained low. Plasma oestradiol followed a similar pattern. Plasma FSH increased more rapidly with bromocriptine than with cyclofenil. There was no significant difference between the treatment groups at any stage for haematology, coagulation or liver function tests. The more sustained effect of cyclofenil on prolactin secretion with a reduced frequency of relapse, and the lower oestradiol level, which might indicate a reduced risk of thromboembolism, suggest that this drug has some advantage over bromocriptine in the inhibition of postpartum lactation.

Local placental influence on the uterine concentration of oestradiol-17 beta and progesterone in the pregnant guinea-pig.

Oestradiol-17 beta (Oe2) and progesterone (P) concentration in the various regions of the uterus, and in ovaries with or without corpora lutea, were determined in the unilaterally pregnant guinea-pig at mid-term and full-term of pregnancy. The concentrations of both Oe2 and P were highest in the non-pregnant horn, and lowest in the perifoetal and juxtaplacental tissue in mid-term and term pregnancies, respectively. The Oe2 concentration in corpus luteum bearing ovaries was much lower than in those without corpora lutea, whereas the P concentration was higher. Ovariectomy performed at term resulted in a decrease of about 40% in plasma P concentration and no significant change in Oe2 concentration. This suggests that there is at least some contribution of P by the ovary even at term of pregnancy. The present data also provide strong evidence for the lack of local placental influence on the concentration of Oe2 and P in the uterus.

Extensive sympathetic denervation of the uterus during pregnancy as evidenced by tyrosine hydroxylase determinations in the guinea pig.

The capacity for neuronal NE synthesis in the guinea pig uterus was studied during pregnancy and postpartum utilizing animals with bilateral or unilateral pregnancies. The activity of the NE-synthesizing enzyme TH was measured in various parts of the uterus. The submandibular gland was used for comparison. During advancing pregnancy the TH activity in the fetus-containing uterine horn was progressively reduced, reaching undetectable levels at term. This change was not seen in the submandibular gland. In parallel with previous fluorescence microscopic observations on uterine adrenergic innervation, the pronounced reduction in TH activity in the fetus-containing uterine horn during progressive pregnancy is suggested to be due to degeneration of the terminal network of adrenergic nerves. In the contralateral empty uterine horn of unilateral pregnancy, the TH activity was decreased by about 90% at term, despite evidence for a relatively intact adrenergic nerve plexus. During the puerperal period the TH activity increased very slowly in the previously empty as well as the fetus-containing horns. In the latter tissue, even at 6 months after delivery, the activity was only 14% of that in uterine horns of virgin animals. In view of the marked regional heterogeneity in the changes, also related to the position and size of the conceptus, it is assumed that they are caused mainly by local humoral and probably also mechanical factors within the uterus.

Adrenergic innervation of the human uterus. Disappearance of the transmitter and transmitter-forming enzymes during pregnancy.

The uterine adrenergic transmitter is in many animal species dramatically reduced during pregnancy, probably leading to a functional denervation near term. In order to clarify whether similar changes also occur in the human uterus, the adrenergic innervation of the isthmic myometrium during nonpregnant and pregnant conditions was analyzed by fluorescence histochemistry for demonstration of adrenergic nerves, and by quantitative measurements of norepinephrine and its synthesizing enzymes, tyrosine hydroxylase and dopa decarboxylase. At term pregnancy all fluorescent adrenergic nerves in the myometrium had disappeared, and the norepinephrine concentration had been reduced to almost zero. Parallel to this the activities of tyrosine hydroxylase and dopa decarboxylase were markedly reduced. By contrast, the activity of the acetylcholine-synthesizing enzyme, choline acetyltransferase, was unchanged, indicating that the adrenergic system was selectively affected. The results confirm that the adrenergic nerves in the human uterus, like those in uterine horns of laboratory animals, undergo fundamental changes in the course of pregnancy. This probably reflects entirely different conditions for a sympathetic influence on the myometrium during the last two trimesters of pregnancy compared to the non-pregnant situation.

Relationship between plasma and uterine oestradiol in pseudopregnant rabbits.

Plasma oestradiol concentrations did not change during hCG-induced pseudopregnancy except for a slight increase on Day 18. However, a marked decline was observed in tissue oestradiol on Day 3 whether expressed on the basis of tissue wet weight or protein. The lowest concentration was found at Day 6 but the Day 18 values were comparable to those of untreated controls.

Uptake and metabolism of [3H]norepinephrine in uterine nerves of pregnant guinea pig.

Myometrial tissue slices from virgin, pregnant (uni- or bilateral pregnancy), and puerperal animals were incubated in media containing [3H]norepinephrine ([3H]NE), and the neuronal and extraneuronal uptake was estimated. The metabolic fate of [3H]NE was elucidated by the chromatographic separation of [3H]NE, [3H]normetanephrine and 3H-labeled acid metabolites. An early and extensive reduction in both total and neuronal uptakes occurred in the myometrial regions surrounding the fetuses, and at term pregnancy no neuronal [3H]NE uptake at all was found in tissue slices from the fetus-containing horns. Concomitantly, the fraction of unchanged [3H]NE decreased with a corresponding increment in its metabolites. Similar changes, though less extensive, also occurred in the empty horn in unilateral pregnancy. The total amount of neuronal uptake in the cervix seemed unchanged compared to virgin animals. Earlier and present data support the following suggestion that in uterine horns harboring fetuses, an extensive axonal degeneration occurs; in those devoid of fetuses (unilateral pregnancy), the nerve terminals are to a great extent structurally intact, but functionally damaged. Recovery of the pregnancy-induced impairment of the adrenergic nerve plexus is slow and incomplete.

Pregnancy-induced alterations in the turnover rate of 3H-noradrenaline formed from 3H-tyrosine in guinea-pig uterus.

The rate of noradrenaline (NA) turnover in the non-pregnant and pregnant guinea-pig uterus was determined after the administration of the labelled precursor, tyrosine. Endogenous NA was determined fluorimetrically. In non-pregnant animals the turnover of 3H-NA was slower in the uterine horns (t1/2 = 10 h) and cervix (t1/2 = 9 h) than in the reference organ, heart (t1/2 = 6 h). During pregnancy (60-65 days post coitum) endogenous NA in the heart increased in pace with tissue weight gain; yet, in the uterus there was a drastic reduction, down to zero levels. 3H-NA turnover increased significantly in the cervix, no 3H-NA formation remained in the uterine horn (a situation resembling that following 6-hydroxydopamine induced sympathectomy of non-pregnant animals), and the turnover was unaltered in the heart. The observations confirm the general idea, illustrated by the results in the heart, of a functional adaptation with a constant neuron-target relationship during increased physiological demands. They also confirm that a very peculiar and complex neuron-target relationship develops in the uterus during pregnancy--involving functional and structural denervation of the adrenergic nerve plexus in the uterine horn, whereas an increased activation might explain the changes in neuronal NA and its turnover in the cervix.

Ultrastructural evidence for adrenergic nerve degeneration in the guinea pig uterus during pregnancy.

In the guinea pig myometrium, the adrenergic nerves selectively demonstrated at the ultrastructural level after treatment with 5-OH-DA, show varying degree of degeneration during pregnancy. The changes are more extensive in a late gestational stage (40-45 days) than in an early one (20-25 days), and are particularly evident in the uterus overlying the conceptus as compared to the regions between the fetuses. Scattered degenerative changes were also observed in myometrial specimens from virgin animals, but probably reflect the normal continuous turnover of axons.

Differential effect on the sympathetic transmitter level in uterus and other organs of guinea-pig by drugs interfering with adrenergic nerve functions.

5 types of adrenergic blocking agents with different modes of action were administered and the rate of transmitter depletion was studied in different uterine regions of guinea-pig, and compared with that in the heart and submandibular gland by a combination of fluorescence histochemical and spectrofluorimetric methods. The tyrosine-hydroxylase inhibitor, H 44/68, as well as reserpine and guanethidine, produced a more efficient reduction in neuronal noradrenaline in the heart and submandibular gland than in the uterus. A differential action on the sympathetic transmitter, though less clearcut, was seen with 6-hydroxydopamine. The noradrenaline-depleting effect of metaraminol did not distinguish between those adrenergic nerves supplying the uterus from those of the control tissues. It is suggested that the differential effects may be related to a lower activity in the uterine adrenergic nerve system, probably because this system is to a large extent composed of short adrenergic neurons, which appear to have a particularly slow transmitter turnover.