Postpartum choriocarcinoma - a rare cause of delayed postpartum hemorrhage: Four case reports and literature review.

BACKGROUND: Delayed postpartum hemorrhage is rare, with an incidence of 0.5% to 2.0% in all pregnancies. The most important causes are placental remnants, infections, and placental bed subinvolution. Postpartum choriocarcinoma, a highly malignant complication of pregnancy, is a rare condition that can be easily misdiagnosed as other common causes, such as gestational remnants, and delays the diagnosis. METHODS: Four patients visited our clinic complaining of delayed postpartum hemorrhage, combined with respiratory and neurological symptoms in 2 cases. Two cases were confirmed by histopathological examination and in addition, medical history, elevated human chorionic gonadotropin (hCG) level, and imaging findings help confirm the diagnosis of delayed postpartum hemorrhage caused by postpartum choriocarcinoma in other cases. Individualized combination chemotherapies were prescribed. In the light of massive cerebral metastasis in case 2, intrathecal methotrexate injection combined with whole-brain radiotherapy was prescribed. RESULTS: Due to the absence of routine monitoring of ß-hCG following full-term delivery, there was widespread metastasis at the time of diagnosis. Three patients got complete remission and there is no sign of recurrence. One patient had relapse and widespread metastasis and died at home 6 months after the last chemotherapy. CONCLUSION: It is important to be aware of the possibility of choriocarcinoma in patients with delayed postpartum hemorrhage. Clinicians should improve the recognition of choriocarcinoma following full-term delivery, emphasize the monitoring of ß-hCG, comprehensively analyze the general condition of patients, and conduct standardized and individualized chemotherapy protocols.

Postpartum ovarian vein thrombophlebitis presenting as vaginal bleeding: A case report.

RATIONALE: Postpartum ovarian vein thrombophlebitis (POVT) is a rare condition, and it can lead to severe complications and mortality. Here we report a patient who presented with vaginal bleeding and the diagnosis of POVT was confirmed by imaging. PATIENT CONCERNS: A 38-year-old postpartum woman without remarkable medical history presented with vaginal bleeding and lower abdominal pain. DIAGNOSES: The diagnosis was confirmed by computed tomography scan marked by a thrombus mass involving the right ovarian vein and inferior vena cava. INTERVENTIONS: The patient was treated with intravenous antibiotics and low-molecular-weight heparin. OUTCOMES: The patient recovered smoothly without complications. LESSONS: We should pay high attention to the recognition and management of POVT to prevent morbidity and mortality.

Insufficient Lactation Leading to Postpartum Diagnosis of Placenta Accreta Spectrum Disorder in a Primigravid Patient.

BACKGROUND: Placenta accreta spectrum is most commonly diagnosed antenatally or at the time of delivery, but it may also present in the postpartum period. CASE: A 29-year-old primigravid patient without risk factors for placenta accreta spectrum had an uncomplicated vaginal birth with normal blood loss and delivery of an intact-appearing placenta. Five days postpartum, she was not lactating and uterine imaging to evaluate for retained products of conception was suspicious for placenta accreta spectrum. She began to develop bleeding in the following days and elected for definitive management. She underwent an uncomplicated hysterectomy on postpartum day 16 and began lactating on postoperative day 1. CONCLUSION: Retained placenta should be included in the differential diagnosis when lactation is insufficient.

Genetics of Peripartum Cardiomyopathy: Current Knowledge, Future Directions and Clinical Implications.

Peripartum cardiomyopathy (PPCM) is a condition in which heart failure and systolic dysfunction occur late in pregnancy or within months following delivery. Over the last decade, genetic advances in heritable cardiomyopathy have provided new insights into the role of genetics in PPCM. In this review, we summarise current knowledge of the genetics of PPCM and potential avenues for further research, including the role of molecular chaperone mutations in PPCM. Evidence supporting a genetic basis for PPCM has emanated from observations of familial disease, overlap with familial dilated cardiomyopathy, and sequencing studies of PPCM cohorts. Approximately 20% of PPCM patients screened for cardiomyopathy genes have an identified pathogenic mutation, with TTN truncations most commonly implicated. As a stress-associated condition, PPCM may be modulated by molecular chaperones such as heat shock proteins (Hsps). Recent studies have led to the identification of Hsp mutations in a PPCM model, suggesting that variation in these stress-response genes may contribute to PPCM pathogenesis. Although some Hsp genes have been implicated in dilated cardiomyopathy, their roles in PPCM remain to be determined. Additional areas of future investigation may include the delineation of genotype-phenotype correlations and the screening of newly-identified cardiomyopathy genes for their roles in PPCM. Nevertheless, these findings suggest that the construction of a family history may be advised in the management of PPCM and that genetic testing should be considered. A better understanding of the genetics of PPCM holds the potential to improve treatment, prognosis, and family management.

Placental site trophoblastic tumour: five challenges of patient clinical management.

Placental site trophoblastic tumour is a rare form of gestational trophoblastic disease accounting for about 1%-2% of all trophoblastic tumours. Diagnosis and management of placental site trophoblastic tumour can be difficult.We report a case of a 30-year-old woman diagnosed with a placental site trophoblastic tumour and identify the challenges in diagnosis and treatment of this rare situation. The presenting sign was abnormal vaginal bleeding that started 3 months after delivery. Image exams revealed an enlarged uterus with a heterogeneous mass, with vesicular pattern, and the increased vascularisation serum human chorionic gonadotropin level was above normal range. The histological diagnosis was achieved through hysteroscopic biopsy. Staging exams revealed pulmonary micronodules. The patient was successfully treated with hysterectomy and chemotherapy. The latest follow-up (37 months after diagnosis) was uneventful, and the patient exhibited no signs of recurrence or metastasis.

MRI activity in MS and completed pregnancy: Data from a tertiary academic center.

OBJECTIVE: To evaluate postpartum MRI activity in patients with MS and a completed pregnancy and to compare these results to an age-matched untreated nonpregnant MS cohort. METHODS: Patient with MS from a tertiary care MS center between 2006 and 2015, with prepartum and postpartum neurologic follow-ups and MRI scans were analyzed. Clinical activity and inflammatory brain MRI activity (new T2-hyperintense or gadolinium-enhancing [Gd+] lesions) were assessed peripartum. The results were compared with untreated reproductive-age patients with MS from the placebo arm of the clinical trials. RESULTS: A total of 123 pregnancies in 123 women (median Expanded Disability Status Scale 1.0) were analyzed. Approximately 7.2% relapsed during pregnancy and 48.7% relapsed postpartum. Of pregnancies with prepartum and postpartum gadolinium (Gd)-enhanced MRI (n = 112), 8% had Gd+ lesions prepartum and 33% had new Gd+ lesions postpartum. Overall, 54.4% had either new T2 or Gd+ lesions postpartum. Seventy-nine percent of subjects with postpartum relapse had new MRI activity compared with 37.1% without relapse (p < 0.001). Twenty-five percent had both clinical and radiographic activity and only 24.9% maintained no evidence of disease activity status postpartum. There was no association between postpartum MRI activity and disease-modifying treatments (DMTs) (p > 0.5). MRI and clinical outcomes were also assessed for 126 nonpregnant untreated female patients with MS. Comparing pregnancy and no pregnancy groups, there was no difference in MRI activity at follow-up. CONCLUSIONS: There was a high level of inflammatory radiographic disease activity which was related to relapses in postpartum patients with MS. Further studies are needed to determine whether hormonal fluctuations vs extended time off DMTs may be the underlying cause of our observations.

Optimal approach for management of postpartum vulva hematoma: Report of three cases.

OBJECTIVE: Vulvar hematomas though common in obstetrical practice can rapidly evolve into a life-threatening condition if not managed appropriately. Depending on clinical status and medical facility, conservative management, surgical debridement, or vessel-occlusion strategy can be considered. CASE REPORT: Case 1 was a 28 year-old pregnant woman. Increasing hematoma over 12 cm in size was noted on postpartum Day 2. Debridement and arterial embolization were done. Case 2 was a referred woman at age of 30 who delivered at a local obstetric clinic. Debridement was performed successfully. Case 3 was a 23 year-old woman with postpartum bilateral hematoma. Drop in hemoglobin level prompted the medical team to transfer and airlift the patient for arterial embolization and subsequent vulva debridement. CONCLUSION: Optimal management of hematoma is dependent on maternal hemodynamic condition, bleeding status, and availability of interventional radiology.

Gestational hypothyroidism elicits more pronounced lipid dysregulation in mice than pre-pregnant hypothyroidism.

Thyroid hormone is crucial for regulating lipid and glucose metabolism, which plays essential role in maintaining the health of pregnant women and their offspring. However, the current literature is just focusing on the development of offspring born to the untreated mothers with hypothyroidism, rather than mothers themselves. Additionally, the interaction between hypothyroidism and pregnancy, and its impact on the women's health are still elusive. Therefore, this study was designed to compare the metabolic differences in dams with hypothyroidism starting before pregnancy and after pregnancy. Pre-pregnant hypothyroidism was generated in 5-week-old female C57/BL/6J mice using iodine-deficient diet containing 0.15% propylthiouracil for 4 weeks, and the hypothyroidism was maintained until delivery. Gestational hypothyroidism was induced in dams after mating, using the same diet intervention until delivery. Compared with normal control, gestational hypothyroidism exhibited more prominent increase than pre-pregnant hypothyroidism in plasma total cholesterol and low-density lipoprotein cholesterol, and caused hepatic triglycerides accumulation. Similarly, more significant elevations of protein expressions of SREBP1c and p-ACL, while more dramatic inhibition of CPT1A and LDL-R levels were also observed in murine livers with gestational hypothyroidism than those with pre-pregnant hypothyroidism. Moreover, the murine hepatic levels of total cholesterol and gluconeogenesis were dramatically and equally enhanced in two hypothyroid groups, while plasma triglycerides and protein expressions of p-AKT, p-FoxO1 and APOC3 were reduced substantially in two hypothyroid groups. Taken together, our current study illuminated that gestational hypothyroidism may elicit more pronounced lipid dysregulation in dams than dose the pre-pregnant hypothyroidism.

Influence of puerperal metritis on the first ovulation after calving in dairy cows.

The aim of this study was to determine how puerperal metritis influences the resumption of estrous cycle in dairy cows. The ovaries of 72 multiparous Holstein cows (38 healthy and 34 metritic - after treatment) were ultrasonographically scanned until the first ovulation postpartum and 7 days after to confirm the ovulation. All 72 cows were divided in to 4 groups: HSO (healthy with single ovulation) (n=29), MSO (metritic with single ovulation) (n=21), HDO (healthy with double ovulation) (n=9), and MDO (metritic with double ovulation) (n=13). The proportion of cows that had DO in the first ovulation postpartum was similar between M and H groups, 38.2% and 23.6%, respectively (p>0.05). There was a difference between HDO and MDO groups comparing the first dominant follicle ovulation postpartum (11.4±2.7 and 20±1 days, respectively p⟨0.05) and the diameter of the ovulatory follicles (15.3±1.9 mm and 17.3±1.7 mm, respectively p0.05). The percentage of cows that had double follicle dominance in the first follicular wave after first ovulation was higher in the M groups (33.3% (MSO) vs. 6.9% (HSO) (p⟨0.05) and (69.2% (MDO) vs. 22.2% (HDO) (p⟨0.05)). The MSO group dominant follicle diameter was bigger for cows which had one dominant follicle (p⟨0.05). It might be concluded that dairy cows after puerperal metritis need more time until the first ovulation. Also, metritic cows have a higher risk for double dominance in the first follicular wave, after the first ovulation.

MOG-IgG myelitis coexisting with systemic lupus erythematosus in the post-partum setting.

BACKGROUND: Longitudinally extensive transverse myelitis (LETM) accompanying systemic lupus erythematosus (SLE) is often due to coexisting aquaporin-4-IgG seropositive neuromyelitis optica spectrum disorder but has not been associated with myelin oligodendrocyte glycoprotein-IgG (MOG-IgG). OBJECTIVE AND METHODS: Case report at an academic medical center. RESULTS: A 32-year-old woman developed severe transverse myelitis (paraplegia) shortly after SLE onset in the post-partum period. Magnetic resonance imaging (MRI) revealed an LETM, cerebrospinal fluid showed marked inflammation, and testing for infections was negative. Serum live-cell-based assay for MOG-IgG was positive but aquaporin-4-IgG was negative. CONCLUSION: In patients with SLE and LETM, MOG-IgG testing should be considered, in addition to AQP4-IgG.

Exacerbations of autoimmune diseases during pregnancy and postpartum.

Autoimmune diseases represent a complex heterogeneous group of disorders that occur as a results of immune homeostasis dysregulation and loss of self-tolerance. Interestingly, more than 80% of the cases are found among women at reproductive age. Normal pregnancy is associated with remarkable changes in the immune and endocrine signaling required to tolerate and support the development and survival of the placenta and the semi-allogenic fetus in the hostile maternal immune system environment. Gravidity and postpartum represent an extremely challenge period, and likewise the general population, women suffering from autoimmune disorders attempt pregnancy. Effective preconception counseling and subsequent gestation and postpartum follow-up are crucial for improving mother and child outcomes. This comprehensive review provides information about the different pathways modulating autoimmune diseases activity and severity, such as the influence hormones, microbiome, infections, vaccines, among others, as well as updated recommendations were needed, in order to offer those women better medical care and life quality.

Characterization of circulating plasma proteins in dairy cows with cytological endometritis.

Early diagnosis of endometritis in dairy cattle is currently requires invasive techniques and specialist expertise. The goal of this study is to utilize a gel-free mass-spectrometry based proteomics approach to compare the plasma proteome of dairy cattle with cytological endometritis to those without. Blood samples were collected from cows (N = 112) seven days postpartum (DPP). Plasma samples from a cohort of 20 animals with cytological endometritis (n = 10) and without (n = 10) as classified 21 DPP were selected for proteomic analysis. Differential abundances of proteins between the two animal groups were determined using both fold change (≥1.5 fold change) and statistical significance threshold (p < .05). A total of 181 non-redundant proteins were quantified, and 25 proteins were found with differential abundance. These include 4 binding protein alpha and mannose binding lectin 2 involved in immune responses. Differentially abundant proteins between the animals were then processed using PANTHER for gene ontology. Gene ontology included associations with innate immune processes, acute phase responses and immune regulation. A potential marker for disease identified here is the "uncharacterized protein G5E513," a protein previously defined by RNA-transcripts. These proteins may form the basis for endometritis prognosis, the development of which is proceeded by systemic changes in immune function. SIGNIFICANCE: Endometritis is a costly reproductive disease of lactating dairy cows that warrants timely diagnosis. We utilized a gel-free mass-spectrometry based proteomics approach to compare the plasma proteome of dairy cattle with cytological endometritis to those without, for the characterization of changes in the proteomic profile associated with uterine disease postpartum. Furthermore, we compared the plasma proteome of healthy and affected cows in the same physiological status of production to better understand the relationship between changes in expression of circulating proteins and to unravel essential biological mechanisms involved in bovine cytological endometritis.