Severe obstetric lacerations associated with postpartum depression among women with low resilience - a Swedish birth cohort study.

OBJECTIVE: Women's levels of resilience and attitudes towards perineal lacerations vary greatly. Some women see them as part of the birthing process, while others react with anger, depressed mood or even thoughts of self-harm. A previous study has reported increased risk of postpartum depressive (PPD) symptoms in women with severe perineal lacerations. The aim of this study was to assess the association between severe obstetric perineal lacerations and PPD. A secondary objective was to assess this association among women with low resilience. DESIGN: Nested cohort study. SETTING: Uppsala, Sweden. SAMPLE: Vaginally delivered women with singleton pregnancies (n = 2990). METHODS: The main exposure was obstetric perineal lacerations. Resilience was assessed in gestational week 32 using the Swedish version of the Sense of Coherence Scale. A digital acyclic graph was used to identify possible confounders and mediators. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). A sub-analysis was run after excluding women with normal or high resilience. MAIN OUTCOME MEASURES: Postpartum depression, assessed with the Depression Self-Reporting Scale, completed at 6 weeks postpartum. RESULTS: There was no significant association between severe obstetric perineal lacerations and PPD at 6 weeks postpartum. However, a significant association was found between severe lacerations and PPD in women with low resilience (OR = 4.8, 95% CI 1.2-20), persisting even after adjusting for confounding factors. CONCLUSION: Healthcare professionals might need to identify women with low resilience, as they are at increased risk for PPD after a severe perineal laceration. TWEETABLE ABSTRACT: Severe perineal lacerations associated with postpartum depression in women with low resilience in a Swedish cohort.

Magnetic resonance imaging-estimated placental perfusion in fetal growth assessment.

OBJECTIVE: To evaluate in-vivo placental perfusion fraction, estimated by magnetic resonance imaging (MRI), as a marker of placental function. METHODS: A study population of 35 pregnant women, of whom 13 had pre-eclampsia (PE), were examined at 22-40 weeks' gestation. Within a 24-h period, each woman underwent an MRI diffusion-weighted sequence (from which we calculated the placental perfusion fraction), venous blood sampling and an ultrasound examination including estimation of fetal weight, amniotic fluid index and Doppler velocity measurements. The perfusion fractions in pregnancies with and without fetal growth restriction were compared and correlations between the perfusion fraction and ultrasound estimates and plasma markers were estimated using linear regression. The associations between the placental perfusion fraction and ultrasound estimates were modified by the presence of PE (P < 0.05) and therefore we included an interaction term between PE and covariates in the models. RESULTS: The median placental perfusion fractions in pregnancies with and without fetal growth restriction were 21% and 32%, respectively (P = 0.005). The correlations between placental perfusion fraction and ultrasound estimates and plasma markers were highly significant (P = 0.002 and P = 0.0001, respectively). The highest coefficient of determination (R(2) = 0.56) for placental perfusion fraction was found for a model that included pulsatility index in the ductus venosus, plasma level of soluble fms-like tyrosine kinase-1, estimated fetal weight and presence of PE. CONCLUSION: The placental perfusion fraction has the potential to contribute to the clinical assessment of cases with placental insufficiency.

In vivo ³¹P-MR spectroscopy in normal pregnancy, early and late preeclampsia: a study of placental metabolism.

INTRODUCTION: Preeclampsia affects about 3% of pregnancies and the placenta is believed to play a major role in its pathophysiology. Lately, the role of the placenta has been hypothesised to be more pronounced in preeclampsia of early (<34 weeks) rather than late (≥ 34 weeks) onset. (31)P Magnetic Resonance Spectroscopy (MRS) enables non-invasive, in vivo studies of placental metabolism. Our aim was to study placental energy and membrane metabolism in women with normal pregnancies and those with early and late onset preeclampsia. METHODS: The study population included fourteen women with preeclampsia (five with early onset and nine with late onset preeclampsia) and sixteen women with normal pregnancy (seven with early and nine with late pregnancy). All women underwent a (31)P-MRS examination of the placenta. RESULTS: The phosphodiester (PDE) spectral intensity fraction of the total (31)P signal and the phosphodiester/phosphomonoester (PDE/PME) spectral intensity ratio was higher in early onset preeclampsia than in early normal pregnancy (p = 0.03 and p = 0.02). In normal pregnancy the PDE spectral intensity fraction and the PDE/PME spectral intensity ratio increased with increasing gestational age (p = 0.006 and p = 0.001). DISCUSSION: Since PDE and PME are related to cell membrane degradation and formation, respectively, our findings indicate increased cell degradation and maybe also decreased cell proliferation in early onset preeclampsia compared to early normal pregnancy, and with increasing gestational age in normal pregnancy. CONCLUSIONS: Our findings could be explained by increased apoptosis due to ischaemia in early onset preeclampsia and also increased apoptosis with increasing gestational age in normal pregnancy.

Placental perfusion in normal pregnancy and early and late preeclampsia: a magnetic resonance imaging study.

OBJECTIVE: Our primary aim was to investigate if women with early or late preeclampsia have different placental perfusion compared with normal pregnancies. A secondary aim was to investigate if placental perfusion changes with increasing gestational age in normal pregnancy. METHODS: The study population included thirteen women with preeclampsia (five with early and eight with late preeclampsia) and nineteen women with normal pregnancy (ten with early and nine with late pregnancy). Early was defined as <34 weeks and late as ≥ 34 weeks gestation. All women underwent a magnetic resonance imaging (MRI) examination including a diffusion weighted sequence at 1.5 T. The perfusion fraction was calculated. RESULTS: Women with early preeclampsia had a smaller placental perfusion fraction (p = 0.001) and women with late preeclampsia had a larger placental perfusion fraction (p = 0.011), compared to women with normal pregnancies at the corresponding gestational age. The placental perfusion fraction decreased with increasing gestational age in normal pregnancies (p = 0.001). CONCLUSION: Both early and late preeclampsia differ in placental perfusion from normal pregnant women. Observed differences are however in the opposite direction, suggesting differences in pathophysiology. Placental perfusion decreases with increasing gestational age in normal pregnancy.

Risk of retained placenta in women previously delivered by caesarean section: a population-based cohort study.

OBJECTIVE: To evaluate whether women with a caesarean section at their first delivery have an increased risk of retained placenta at their second delivery. DESIGN: Population-based cohort study. SETTING: Sweden. POPULATION: All women with their first and second singleton deliveries in Sweden during the years 1994-2006 (n = 258,608). Women with caesarean section or placental abruption in their second pregnancy were not included in the study population. METHODS: The risk of retained placenta at second delivery was estimated for women with a first delivery by caesarean section (n = 19,458), using women with a first vaginal delivery as reference (n = 239,150). Risks were calculated as odds ratios by unconditional logistic regression analysis with 95% confidence intervals (95%) after adjustments for maternal, delivery, and infant characteristics. MAIN OUTCOME MEASURES: Retained placenta with normal (≤1000 ml) and heavy (>1000 ml) bleeding. RESULTS: The overall rate of retained placenta was 2.07%. In women with a previous caesarean section and in women with previous vaginal delivery, the corresponding rates were 3.44% and 1.96%, respectively. Compared with women with a previous vaginal delivery, women with a previous caesarean section had an increased risk of retained placenta (adjusted OR 1.45; 95% CI 1.32-1.59), and the association was more pronounced for retained placenta with heavy bleeding (adjusted OR 1.61; 95% CI 1.44-1.79). CONCLUSIONS: Our report shows an increased risk for retained placenta in women previously delivered by caesarean section, a finding that should be considered in discussions of mode of delivery.

Massive postpartum hemorrhage treated with transcatheter arterial embolization: technical aspects and long-term effects on fertility and menstrual cycle.

BACKGROUND: Transcatheter arterial embolization (TAE) is considered a safe, life-saving procedure in postpartum hemorrhage (PPH), but its long-term effect on menstruation and fertility is unclear. PURPOSE: To investigate technical aspects and the evaluation of complications, focused on menstrual cycle and fertility, using TAE in patients with PPH. MATERIAL AND METHODS: A retrospective study including 20 patients (seven with vaginal and 13 with cesarean delivery) with severe PPH treated with bilateral TAE of the uterine artery was carried out. All patients were asked to answer a questionnaire regarding their post-embolization history. In six patients, the radiation dose was measured. RESULTS: All 20 cases underwent bilateral TAE of the uterine artery. Gelfoam was used as the embolic agent. However, after cesarean delivery in six patients who had clear contrast medium extravasation and/or pseudoaneurysm-like lesion, metallic coils had to be used in order to achieve hemostasis. No major short- or long-term complications were registered. Normal menses resumed in all patients. Four patients had a total of five full-term and two preterm pregnancies, and all delivered healthy infants by cesarean section with no recurrence of PPH. The mean radiation dose to the ovaries was 586 mGy (range 204-729 mGy). CONCLUSION: TAE in patients with PPH is safe and has no major short- or long-term side effects. A patient managed with TAE can expect return of normal menses and preservation of future fertility and successful pregnancies. PPH after cesarean section might need to be embolized with metallic coils in addition to Gelfoam in order to achieve secure hemostasis.

Ultrasound finding of an echogenic mass in women with secondary postpartum hemorrhage is associated with retained placental tissue.

OBJECTIVES: To describe sonographic findings associated with retained placental tissue in patients with secondary postpartum hemorrhage, and to compare these findings with those of women with a normal puerperium. METHODS: This was a prospective observational study of 79 women with secondary postpartum hemorrhage. Ultrasound examinations were performed on the day the patients presented with clinical symptoms and were scheduled for postpartum days 1, 3, 7, 14, 28 and 56, continuing until uterine surgical evacuation was performed or until the bleeding stopped. The maximum anteroposterior (AP) diameters of the uterus and uterine cavity were measured and morphological findings in the cavity were recorded. The findings were compared with previously published results from a normal population. RESULTS: The patients were divided into two groups. Group 1 (n = 18) underwent surgery and Group 2 (n = 61) was treated conservatively. Sonography revealed an echogenic mass in the uterine cavity in 17 patients from Group 1, and in 14 of these patients histology confirmed placental tissue. The AP diameter of the uterine cavity was above the 90(th) percentile in all but two of the 18 Group 1 patients. In 18 patients from Group 2 the cavity was empty and in 43 a mixed-echo pattern was found. The uterine cavity was wider compared with the controls, but the values largely overlapped. CONCLUSION: This report supports the opinion that the sonographic finding of an echogenic mass in the uterine cavity in women with secondary postpartum hemorrhage is associated with retained placental tissue.

Ultrasonic evaluation of the uterus and uterine cavity after normal, vaginal delivery.

OBJECTIVE: To describe uterine and uterine cavity changes throughout the puerperium, as revealed by ultrasound. METHODS: This was a prospective, longitudinal study in which 42 women with uncomplicated vaginal term deliveries were examined serially by ultrasound on postpartum days 1, 3, 7, 14, 28 and 56. The first four examinations were performed transabdominally and the last two transvaginally. The involution process of the uterus was assessed by measuring the anteroposterior diameter of the uterus and uterine cavity. Morphological findings were recorded. The influence on the involution process of parity, breast-feeding, maternal smoking and infant's birth weight were also evaluated. RESULTS: The maximum anteroposterior diameter of the uterus diminished substantially and progressively from 92.0 mm on day 1 postpartum to 38.9 mm on day 56. The maximum anteroposterior diameter of the uterine cavity diminished from 15.8 mm on day 1 to 4.0 mm on day 56. However, the anteroposterior diameter of the uterine cavity, 5 cm from the fundus, typically increased on days 7 and 14 postpartum. The position of the uterus and the shape and the appearance of the cavity change in a unique way during the normal puerperium. The uterus was most often retroverted and empty in the early puerperium. Fluid and debris in the whole cavity were seen in the middle part of the puerperium. In late puerperium the cavity was empty and appeared as a thin white line. Endometrial gas was occasionally visualized. No correlation was found between the involution of the uterus and parity, breast-feeding and the infant's birth weight. CONCLUSION: Transabdominal sonography is suitable for examination of the uterus during the first 14 days postpartum but from day 28 the transvaginal route is preferable. The uterine body and position, as well as the cavity, are easy to examine by ultrasound. Accumulation of fluid and debris in the uterine cavity is a common and insignificant finding of the involuting uterus. It is located in the cervical area in the early puerperium and in the whole uterine cavity in the middle part of the puerperium. Findings from uncomplicated vaginal deliveries are needed as a reference when the diagnostic efficacy of ultrasound for pathological conditions is to be tested.