-
The New England Journal of Medicine Jul 2023Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Delays in the detection or treatment of postpartum hemorrhage can result in complications or death. A blood-collection drape can help provide objective, accurate, and early diagnosis of postpartum hemorrhage, and delayed or inconsistent use of effective interventions may be able to be addressed by a treatment bundle.
METHODS
We conducted an international, cluster-randomized trial to assess a multicomponent clinical intervention for postpartum hemorrhage in patients having vaginal delivery. The intervention included a calibrated blood-collection drape for early detection of postpartum hemorrhage and a bundle of first-response treatments (uterine massage, oxytocic drugs, tranexamic acid, intravenous fluids, examination, and escalation), supported by an implementation strategy (intervention group). Hospitals in the control group provided usual care. The primary outcome was a composite of severe postpartum hemorrhage (blood loss, ≥1000 ml), laparotomy for bleeding, or maternal death from bleeding. Key secondary implementation outcomes were the detection of postpartum hemorrhage and adherence to the treatment bundle.
RESULTS
A total of 80 secondary-level hospitals across Kenya, Nigeria, South Africa, and Tanzania, in which 210,132 patients underwent vaginal delivery, were randomly assigned to the intervention group or the usual-care group. Among hospitals and patients with data, a primary-outcome event occurred in 1.6% of the patients in the intervention group, as compared with 4.3% of those in the usual-care group (risk ratio, 0.40; 95% confidence interval [CI], 0.32 to 0.50; P<0.001). Postpartum hemorrhage was detected in 93.1% of the patients in the intervention group and in 51.1% of those in the usual-care group (rate ratio, 1.58; 95% CI, 1.41 to 1.76), and the treatment bundle was used in 91.2% and 19.4%, respectively (rate ratio, 4.94; 95% CI, 3.88 to 6.28).
CONCLUSIONS
Early detection of postpartum hemorrhage and use of bundled treatment led to a lower risk of the primary outcome, a composite of severe postpartum hemorrhage, laparotomy for bleeding, or death from bleeding, than usual care among patients having vaginal delivery. (Funded by the Bill and Melinda Gates Foundation; E-MOTIVE ClinicalTrials.gov number, NCT04341662.).
Topics: Female; Humans; Pregnancy; Early Diagnosis; Oxytocics; Postpartum Hemorrhage; Risk; Tranexamic Acid
PubMed: 37158447
DOI: 10.1056/NEJMoa2303966 -
The Breast Journal 2024Idiopathic granulomatous mastitis (IGM) is a rare, benign inflammatory disorder of the breast that is often underrecognized. The exact etiology and pathophysiology are... (Review)
Review
Idiopathic granulomatous mastitis (IGM) is a rare, benign inflammatory disorder of the breast that is often underrecognized. The exact etiology and pathophysiology are unknown, but milk stasis is felt to play a role. Classically, this condition is noninfectious, but many cases are noted to be associated with species. Most patients affected are parous women with a mean age of 35, and many have breastfed within five years of diagnosis. Patients typically present with a painful mass and symptoms of inflammation, and these features can sometimes mimic breast cancer. Biopsy is needed to make a definitive diagnosis, and noncaseating granulomas are found on core biopsy. Many patients have a waxing and waning course over a period of six months to two years. Goal of treatment is to avoid surgery given poor wound healing, high risk of recurrence, and poor cosmetic outcomes. Medical treatment is preferred and includes observation, antibiotics, steroids, and immune modulators such as methotrexate. In more recent years, topical and intralesional steroids have become the treatment of choice, with similar outcomes to oral steroids.
Topics: Female; Humans; Adult; Granulomatous Mastitis; Breast Neoplasms; Neoplasm Recurrence, Local; Breast; Steroids
PubMed: 38304866
DOI: 10.1155/2024/6693720 -
Revista Portuguesa de Cardiologia :... Nov 2023Peripartum cardiomyopathy is a rare type of heart failure manifesting towards the end of pregnancy or in the months following delivery, in the absence of any other cause... (Review)
Review
Peripartum cardiomyopathy is a rare type of heart failure manifesting towards the end of pregnancy or in the months following delivery, in the absence of any other cause of heart failure. There is a wide range of incidence across countries reflecting different population demographics, uncertainty over definitions and under-reporting. Race, ethnicity, multiparity and advanced maternal age are considered important risk factors for the disease. Its etiopathogenesis is incompletely understood and is likely multifactorial, including hemodynamic stresses of pregnancy, vasculo-hormonal factors, inflammation, immunology and genetics. Affected women present with heart failure secondary to reduced left ventricular systolic function (LVEF <45%) and often with associated phenotypes such as LV dilatation, biatrial dilatation, reduced systolic function, impaired diastolic function, and increased pulmonary pressure. Electrocardiography, echocardiography, magnetic resonance imaging, endomyocardial biopsy, and certain blood biomarkers aid in diagnosis and management. Treatment for peripartum cardiomyopathy depends on the stage of pregnancy or postpartum, disease severity and whether the woman is breastfeeding. It includes standard pharmacological therapies for heart failure, within the safety restrictions for pregnancy and lactation. Targeted therapies such as bromocriptine have shown promise in early, small studies, with large definitive trials currently underway. Failure of medical interventions may require mechanical support and transplantation in severe cases. Peripartum cardiomyopathy carries a high mortality rate of up to 10% and a high risk of relapse in subsequent pregnancies, but over half of women present normalization of LV function within a year of diagnosis.
Topics: Pregnancy; Female; Humans; Peripartum Period; Cardiomyopathies; Heart Failure; Prognosis; Echocardiography; Puerperal Disorders; Pregnancy Complications, Cardiovascular
PubMed: 37414337
DOI: 10.1016/j.repc.2023.01.029 -
The Psychiatric Clinics of North America Sep 2023Perinatal depression is a common psychiatric condition that has negative effects on pregnancy and infant outcomes. Screening for the condition is relatively easy and... (Review)
Review
Perinatal depression is a common psychiatric condition that has negative effects on pregnancy and infant outcomes. Screening for the condition is relatively easy and should be done routinely in all medical care of the pregnant and postpartum woman and her infant. The risk-benefit analysis favors the use of antidepressant medications during pregnancy and lactation compared with the risk of untreated maternal depression. Other, nonpharmacological treatments will be discussed as well as new treatments, including a new class of medications that act on the inhibitory GABAergic neurotransmitter system.
Topics: Pregnancy; Female; Infant; Humans; Depression; Depression, Postpartum; Depressive Disorder; Antidepressive Agents; Pregnancy Complications
PubMed: 37500243
DOI: 10.1016/j.psc.2023.04.003 -
The New England Journal of Medicine Jan 2024
Review
Topics: Female; Humans; Cardiomyopathies; Peripartum Period; Puerperal Disorders; Pregnancy Complications, Cardiovascular
PubMed: 38197818
DOI: 10.1056/NEJMra2306667 -
Anasthesiologie, Intensivmedizin,... Oct 2023Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section... (Review)
Review
Postpartum hemorrhage (PPH) affects about 4% of all deliveries in high-income countries and continues to rise, a trend attributable to the increase in caesarean section rates and maternal morbidity. Preventive measures such as the precautionary administration of uterotonics effectively reduce the risk of severe bleeding irrespective of birth mode. As a time-critical condition and a significant contributor to adverse maternal outcomes, PPH needs to be diagnosed early by measuring, not estimating, blood losses. Institutional treatment algorithms should be available to guide stage-based interdisciplinary management without delay. The main therapy goals are to identify the etiology and stop the bleeding by using uterotonics and mechanical and surgical interventions, to restore hemodynamic stability by volume and transfusion therapy and to optimize hemostasis by laboratory- and viscoelastic assay-guided factor replacement. This review highlights current recommendations for prevention, diagnosis and treatment of PPH.
Topics: Pregnancy; Female; Humans; Postpartum Hemorrhage; Oxytocics; Cesarean Section; Blood Transfusion
PubMed: 37832561
DOI: 10.1055/a-2043-4451 -
Journal of Affective Disorders Oct 2023Postpartum depression (PPD) is a prevalent public health issue. Although ketamine has prophylactic effects on PPD in women undergoing cesarean section, the effects of... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Postpartum depression (PPD) is a prevalent public health issue. Although ketamine has prophylactic effects on PPD in women undergoing cesarean section, the effects of esketamine on PPD remain unclear. This trial aimed to evaluate the efficacy of perioperative esketamine infusion on PPD risk by assessing Edinburgh Postnatal Depression Scale (EPDS) scores and blood biomarkers.
METHODS
A total of 150 participants undergoing elective cesarean section were randomly allocated to receive either esketamine or normal saline. Since 27 participants were excluded due to consent withdrawal or loss to follow-up, 123 patients were included. The primary outcome was the prevalence of PPD risk. Secondary outcomes included the prevalence of postpartum anxiety (PPA) risk, levels of biomarkers, postoperative pain intensity, and cumulative sufentanil consumption.
RESULTS
The prevalence of PPD and PPA risk at 3 days, 42 days, 3 months, and 6 months postpartum did not differ between the two groups. Furthermore, EPDS scores, pain intensity at rest, and during coughing on postoperative days (POD) 1 and 2 did not differ between the two groups. Sufentanil consumption during 0-12 h, 12-24 h, 0-24 h, and 0-48 h postoperatively were significantly lower in the esketamine group compared to the control group. Blood biomarkers did not differ between the two groups on POD 3.
LIMITATIONS
The sample size was small. PPD risk was simply screened, not diagnosed.
CONCLUSIONS
Perioperative administration of esketamine did not decrease the incidence of PPD risk in women after elective cesarean section. However, esketamine reduced opioid consumption.
Topics: Humans; Female; Pregnancy; Cesarean Section; Ketamine; Depression, Postpartum; Sufentanil; Biomarkers
PubMed: 37482224
DOI: 10.1016/j.jad.2023.07.103 -
The New England Journal of Medicine Apr 2024
Topics: Female; Humans; Peripartum Period; Cardiomyopathies; Puerperal Disorders
PubMed: 38631014
DOI: 10.1056/NEJMc2401629 -
Revue de L'infirmiere 2024
Topics: Humans; Female; Postpartum Hemorrhage; Pregnancy; Adaptation, Psychological
PubMed: 38901916
DOI: 10.1016/j.revinf.2024.05.018 -
Bipolar Disorders May 2024The perinatal period is an extremely delicate phase that can involve a high risk for onset of depressive disorders. The Edinburgh Postnatal Depression Scale (EPDS) is a... (Review)
Review
The perinatal period is an extremely delicate phase that can involve a high risk for onset of depressive disorders. The Edinburgh Postnatal Depression Scale (EPDS) is a widely validated instrument for assessing perinatal depressive symptoms, including the dimension of anhedonia. There are studies suggesting that the neural mechanism underlying the occurrence of anhedonia in patients with major depressive disorder (MDD) and bipolar depression (BD) might be distinct. Anhedonia seems to represent a more stable and frequent symptom in women with postpartum bipolar relative to unipolar depressive disorder and is associated with significantly higher depressive symptom severity. Perinatal medicine is an important component of women's health. Treatment of anhedonia can be challenging, and the most effective treatment can be a combination of psychotherapy and medication, but the screening of anhedonia in peripartum women can prevent the development of other psychiatric disorders and maladaptive behaviors.
Topics: Humans; Female; Anhedonia; Peripartum Period; Pregnancy; Bipolar Disorder; Depressive Disorder, Major; Depression, Postpartum
PubMed: 38302845
DOI: 10.1111/bdi.13408