Short term sequelae of preeclampsia: a single center cohort study.

BACKGROUND: Data on the prevalence of persistent symptoms in the first year after preeclampsia are limited. Furthermore, possible risk factors for these sequelae are poorly defined. We investigated kidney function, blood pressure, proteinuria and urine sediment in women with preeclampsia 6 months after delivery with secondary analysis for possible associated clinical characteristics. METHODS: From January 2007 to July 2014 all women with preeclampsia and 6-months follow up at the University Hospital Basel were analyzed. Preeclampsia was defined as new onset of hypertension (≥140/90 mmHg) and either proteinuria or signs of end-organ dysfunction. Hypertension was defined as a blood pressure ≥ 140/90 mmHg or the use of antihypertensive medication. Proteinuria was defined as a protein-to-creatinine ratio in a spot urine > 11 mg/mmol. Urine sediment was evaluated by a nephrologist. Secondary analyses were performed to investigate for possible parameters associated with persistent symptoms after preeclampsia. RESULTS: Two hundred two women were included into the analysis. At a mean time of follow up of 172 days (+/- 39.6) after delivery, mean blood pressure was 124/76 mmHg (+/- 14/11, range 116-182/63-110) and the mean serum-creatinine was 61.8 µmol/l (33-105 µmol/l) (normal < 110 µmol/l). Mean estimated glomerular filtration rate using CKD-EPI was 110.7 mml/min/1.73m2 (range 59.7-142.4 mml/min/1.73m2) (normal > 60 mml/min/1.73m2). 20.3% (41/202) had a blood pressure of 140/90 mmHg or higher (mean 143/89 mmHg) or were receiving antihypertensive medication (5.5%, 11/202). Proteinuria was present in 33.1% (66/199) (mean 27.5 mg/mmol). Proteinuria and hypertension was present in 8% (16/199). No active urine sediment (e.g. signs of glomerulonephritis) was observed. Age and gestational diabetes were associated with persistent proteinuria and severe preeclampsia with eGFR decline of ≥ 10 ml/min/1.73m2. CONCLUSION: Hypertension and proteinuria are common after 6 months underlining the importance of close follow up to identify those women who need further care.

Ketoacidosis in a non-diabetic woman who was fasting during lactation.

Ketoacidosis is a potential complication of type 1 diabetes. Severe ketoacidosis with a blood pH below 7.0 is only rarely seen in other diseases.Three weeks after delivery, a young woman was admitted because of tachypnoe and tachycardia. Blood gas analysis showed a severe metabolic acidosis with a high anion gap. Further workup revealed the presence of ketone bodies in the urine with normal blood glucose and no history of diabetes. The patient reported that she had not eaten for days because of abdominal pain. After initial treatment in the ICU and immediate re-feeding, the patient's condition rapidly improved.While under normal circumstances fasting causes at most only mild acidosis, it can be dangerous during lactation. Prolonged fasting in combination with different forms of stress puts breast feeding women at risk for starvation ketoacidosis and should therefore be avoided.

Postpartum microalbuminuria after gestational diabetes: the impact of current glucose tolerance status.

CONTEXT: It has been reported that women with a history of gestational diabetes mellitus (GDM) have an increased risk of microalbuminuria compared with that of their peers. Because previous GDM predicts an increased risk of prediabetes, which itself is associated with microalbuminuria, we hypothesized that current glucose intolerance may confound any association between GDM and microalbuminuria. OBJECTIVE: The purpose of this study was to evaluate the relative impact of gestational and current dysglycemia on postpartum microalbuminuria in a cohort of women reflecting the full spectrum of gestational glucose tolerance from normal to mildly abnormal to GDM. DESIGN/SETTING/PARTICIPANTS: In this prospective observational cohort study, 320 women underwent a glucose challenge test (GCT) and an oral glucose tolerance test (OGTT) in pregnancy, which identified 100 women with GDM, 58 with gestational impaired glucose tolerance, 90 with an abnormal GCT but a normal OGTT, and 72 with a normal GCT and OGTT. At 3 years postpartum, they underwent measurement of urine microalbumin and a repeat OGTT that identified 63 women with glucose intolerance (prediabetes/diabetes). RESULTS: The postpartum urine microalbumin to creatinine ratio did not differ among the 4 gestational glucose tolerance groups (P = .23). Furthermore, on logistic regression analysis, GDM did not independently predict an elevated urine microalbumin to creatinine ratio of ≥1.5 g/mol of creatinine (odds ratio, 0.43; 95% confidence interval, 0.17-1.11), after adjustment for age, ethnicity, family history of diabetes, body mass index, blood pressure, estimated glomerular filtration rate, and current glucose intolerance. In contrast, current glucose intolerance independently predicted a urine microalbumin to creatinine ratio of ≥1.5 (odds ratio, 3.4; 95% confidence interval, 1.4-8.2, P = .005). CONCLUSION: Current glucose intolerance, rather than previous GDM, may be associated with an increased risk of microalbuminuria in the early postpartum years.

Melatonin level and pattern in postpartum versus nonpregnant nulliparous women.

OBJECTIVE: To compare 24-hour melatonin level and timing in postpartum and nonpregnant nulliparous women. Melatonin release provides information regarding circadian rhythm timing, which influences health. DESIGN: 2-group comparison of data derived from intensive within-subject data collection. SETTING: Participants' typical daily environment. PARTICIPANTS: 38 postpartum and 20 nonpregnant nulliparous women. Mothers' infants were 4 to 10 weeks of postnatal age. MAIN OUTCOME MEASURES: Urinary 6-sulfatoxymelatonin assayed from each voiding and corrected for volume using creatinine. RESULTS: Postpartum women had significantly higher baseline, lower maximum, lower percent rise, and differing pattern of 6-sulfatoxymelatonin than nonpregnant nulliparous women. CONCLUSION: Differences in melatonin suggest possible circadian rhythm disruption in the postnatal period.

Urinary excretion of collagen degradation markers by sows during postpartum uterine involution.

Incomplete uterine involution is the putative cause of the increased embryo mortality and reproductive failure often exhibited by sows that lactate for less than 21 days. Since such short lactation lengths are common in American swine production, an effective technique to monitor the postpartum involution process and test this hypothesis might be valuable. Rapid and extensive catabolism of uterine collagen is essential for normal postpartum involution. The objective of this study was to characterize postpartum excretion of two biochemical markers of collagen degradation. In experiment I, urine samples were collected from five sows every other day from the day before parturition (day -1), through a 21-day lactation, to day 8 postweaning. The collagen crosslinks hydroxylysyl pyridinoline (HP), which is present in many tissues, and lysyl pyridinoline (LP), which is primarily concentrated in bone, were assayed by both ELISA and HPLC. Urinary levels of both free (ELISA) and total (HPLC) HP and LP increased (P < 0.001) approximately two-fold during lactation. The mean molar ratio of total HP:LP increased (P < 0.001) from 6.6 +/- 1.6 at day 1 to a maximum of 10.2 +/- 1.5 at day 7 postpartum and averaged 9.1 +/- 0.3 for the entire sampling period. These data are consistent with a postpartum increase of soft tissue collagen catabolism since bone has a low HP:LP ratio of 4 and soft tissues like the uterus have a high HP:LP ratio of >/=20 because they contain only trace amounts of LP. Since HPLC (total) and ELISA (free) crosslinks estimates were highly correlated (r = 0.85-0.91, P < 0.001) in experiment I, only the less technical ELISA technique was used in experiment II. Urine samples were collected from 21 sows every third day from day 1 to 19 of lactation. Sows from this second group exhibited one of four distinct crosslinks excretion patterns: peak on day 1 (n = 3), peak on day 7 (n = 4), peak on day 10, 13 or 16 (n = 7), or no peak (n = 7). This variation of postpartum crosslinks excretion among sows was not related to parity, body weight, lactation body weight change, litter size, or litter birth weight. Overall, data from experiments I and II indicate that urinary HP does increase postpartum in a pattern temporally consistent with uterine involution. However, significant variation among sows in the magnitude and timing of peak HP excretion was evident.

Iodine deficiency in ambulatory participants at a Sydney teaching hospital: is Australia truly iodine replete?

OBJECTIVE: To assess iodine status in four separate groups--pregnant women, postpartum women, patients with diabetes mellitus and volunteers. DESIGN AND SETTING: Prospective cross-sectional study at a tertiary referral hospital in Sydney. PARTICIPANTS: 81 pregnant women attending a "high risk" obstetric clinic; 26 of these same women who attended three months postpartum; 135 consecutive patients with diabetes mellitus attending the diabetes clinic for an annual complications screen; and 19 volunteers. There were no exclusion criteria. METHODS: Spot urine samples were obtained, and urinary iodine was measured by inductively coupled plasma mass spectrometer. OUTCOME MEASURES: Iodine status based on urinary iodine concentration categorised as normal (> 100 micrograms/L), mild deficiency (51-100 micrograms/L) and moderate to severe deficiency (< 50 micrograms/L). RESULTS: Moderate to severe iodine deficiency was found in 16 pregnant women (19.8%), five postpartum women (19.2%), 46 patients with diabetes (34.1%) and five volunteers (26.3%). Mild iodine deficiency was found in an additional 24 pregnant women (29.6%), nine postpartum women (34.6%), 51 patients with diabetes (37.8%) and 9 normal volunteers (47.4%). Median urinary iodine concentration was 104 micrograms/L in pregnant women, 79 micrograms/L in postpartum women, 65 micrograms/L in patients with diabetes mellitus and 64 micrograms/L in volunteers. CONCLUSIONS: The high frequency of iodine deficiency found in our participants suggests that dietary sources of iodine in this country may no longer be sufficient. Further population studies are required.

Morbidity and mortality from postpartum hypertension in Nigerian women.

Two hundred and ten patients who were normotensive during pregnancy and labour but developed hypertension during puerperium have been studied. Two groups were identified with this unexpected postpartum hypertension. Although the patients in group A who had earlier onset hypertension were younger and mainly nulliparas, there was no significant difference between both groups with respect to age, serum creatinine, blood urea, blood pressures and presence of abnormal urine sediment at the onset of illness. The incidence of postpartum hypertension was 3.5. per cent; there was remission of hypertension in 8 patients (3.8%) without treatment, recurrence in 17 (8%) while cardiac failure occurred in (5.4%), cerebrovascular accident in 3 (1.4%) and acute oliguric renal failure in 3 (1.4%). Overall mortality was 0.9 per cent while persistent or chronic hypertension was observed in 52 (23.8%) Postpartum hypertension is a definite clinical entity with significant morbidity and mortality. Frequent monitoring of blood pressure in the puerperium is advocated to avoid or reduce cardiovascular, cerebrovascular and renal complications of postpartum hypertension in susceptible women.

Idiopathic myoglobinuria in the early puerperium.

Myoglobinuria is rare in association with pregnancy. We report a case of idiopathic myoglobinuria in the early puerperium in a patient who had a spontaneous vaginal delivery. Acute muscular pain and port wine staining of the urine should alert the clinician.

Urinary albumin excretion in diabetic pregnancy.

We have analysed the results of urinary albumin excretion in timed overnight urine samples once every two weeks during pregnancy and post-natally in 25 non-diabetic women and 14 women with Type 1 (insulin-dependent) diabetes who were Albustix negative and had urinary albumin excretion less than 15 micrograms.min-1 at conception. Urinary albumin excretion did not vary significantly in the first two trimesters in either group and at 28 weeks was 2.73 micrograms.min-1 (0.32-251.68) (median and range) in the diabetic women and 2.53 micrograms.min-1 (0.90-13.37) in control patients (not significant). During the third trimester urinary albumin excretion increased, and levels were significantly higher in diabetic patients from 36 weeks (9.37 (0.9-31.78) vs 3.52 (0.19-33.74) micrograms.min-1, p less than 0.01) until delivery. In both groups, urinary albumin excretion reached a peak within the week following delivery - diabetic 17.42 micrograms.min-1 (2.03-46.64), control subjects 16.29 micrograms.min-1 (1.53-35.56), but six weeks after delivery, levels were similar to those in early pregnancy. The effect of pregnancy on urinary albumin excretion in these diabetic women would appear to be an exaggeration of the normal pattern, with levels returning to normal post-delivery. It is not possible to know if this has significance for future renal function, but it would be important to investigate this phenomenon in patients who already have raised urinary albumin excretion at conception.

Bovine postparturient hemoglobinemia: hypophosphatemia and metabolic disorder in red blood cells.

Mechanism of hemolysis in postparturient hemoglobinemia was studied in 7 cows. Cows 1 to 5 had a history of hemoglobinemia at a previous calving, but hemoglobinemia did not occur during the present parturition. Cow 6, a daughter of cow 4, and cow 7 from another farm, developed postparturient hemoglobinemia and had hemoglobinuria on days 20 and 21 and 10 to 17 after calving, respectively. During the time cows 6 and 7 had hemoglobinuria, both cows had a marked decrease in serum inorganic phosphorus, RBC adenosine 5'-triphosphate (ATP), and reduced glutathione, and a significant (P less than 0.01) increase in methemoglobin concentration. In cow 6, these changes were observed before the onset of hemoglobinuria, indicating metabolic disorder of RBC. After phosphate administration IV, serum inorganic phosphorus was corrected, and RBC ATP was increased above base-line value. During the time cows 6 and 7 had hemoglobinuria, PCV, hemoglobin concentration, and RBC count decreased progressively and reached nadir values, 40% to 50% of baseline values, on day 22 in cow 6 and on day 19 in cow 7. Cows 6 and 7 were anemic, even after serum inorganic phosphorus and RBC ATP values returned to acceptable values. Glycolytic disorder and depletion of ATP, resulting from phosphorus deficiency, appeared to be a primary and essential step leading to hemolysis in postparturient hemoglobinemia in cows 6 and 7.

Pregnancy-induced hypertension and postpartum maternal morbidity.

Prospective evaluation of 80 patients experiencing preeclampsia/eclampsia was conducted. Traditional antepartum clinical presentation, classification, and laboratory evaluation were found to be imprecise for the prediction of postpartum maternal morbidity. Serial urine samples were collected from all patients during the antepartum, intrapartum, and postpartum period. Urine albumin and immunoglobulin G (IgG) concentrations were measured by rate nephelometry. The degree of albumin and IgG excretion before and after standard treatment modalities correlates with the occurrence of postpartum morbidity. The nephelometric urinalysis appears to be of assistance in the evaluation of disease severity, the effectiveness of treatment modalities on renal function, and the identification of patients destined to develop postpartum morbidity. In addition, rapid nephelometric urinalysis makes the collection of 24-hour urine samples unnecessary for evaluation of renal function in pregnancy-induced hypertension.

Influence of the HLA-DR4 antigen and iodine status on the development of autoimmune postpartum thyroiditis.

HLA-A, -B, and -DR antigens were determined in all 50 women with a serum thyroid microsomal hemagglutination antibody (MsAb) titer equal to or greater than 1:100 in the first trimester of pregnancy in a population of 733 pregnant women. The DR4 antigen was found in 58.0% of the women compared to 33.7% in control subjects, which corresponds to a relative risk of 2.71 (P less than 0.01 by X2 test). The MsAb-positive women were examined regularly during the year after delivery for the development of thyroid dysfunction. The DR4 antigen frequency was found to be even higher, 69.0% (relative risk = 4.36; P less than 0.001), among the 29 women who developed hypothyroidism in the postpartum period. No other HLA antigen deviations were found among those 15 hypothyroid women in whom an initial thyrotoxic phase occurred before hypothyroidism. The B8, DR3 haplotype was found in 3 of 5 women who developed Graves' thyrotoxicosis alone. Urinary iodine excretion measured in some MsAb-positive women 3 (n = 19) or 6 months (n = 29) postpartum, respectively, was compatible with leakage of thyroid iodine during the initial destruction-induced thyrotoxic phase of postpartum thyroiditis, followed by low iodine excretion during the subsequent hypothyroid phase. We conclude that genes coding for the DR4 antigen may have a regulatory influence on MsAb production, which in turn affects the development of postpartum hypothyroidism. Thyroid iodine content and iodine intake also may have an impact on the severity of the thyrotoxic and the hypothyroid phases of autoimmune postpartum thyroiditis.

Arginine-vasopressin in postpartum panhypopituitarism: urinary excretion and kidney response to osmolar load.

The response to an osmolar load (750 ml 2.5% NaCl solution iv preceded by 500 ml water by mouth) was studied in 20 patients with Sheehan's syndrome and 12 normal women. Sodium and osmolality were determined in plasma and urine and arginine-vasopressin (AVP) was measured by RIA in urine. The test was performed in each patient when untreated (group P), after hydrocortisone replacement alone (group F), and combined hydrocortisone and thyroid hormone replacement (group F+T). After the osmolar loading, maximum urinary osmolality in the patients was lower than in the normal women and remained unaffected by both hydrocortisone alone and hydrocortisone and thyroid hormone. Comparison of the mean hourly urinary volume before and after NaCl infusion demonstrated an increase in group P, a decrease in group C, and no change in groups F and F+T. Although free water clearance became negative in all groups, values in groups P, F, and F+T were constantly above that of group C. None of the patients in groups P and F had a significant rise in urine AVP excretion during or after NaCl infusion. Those in group F+T had a slight AVP response which was less than in normal women. Impaired response of AVP to an osmolar load appears to be a constant feature of Sheehan's syndrome even without overt diabetes insipidus.

Emotional disturbance following childbirth: clinical findings and urinary excretion of cyclic AMP (adenosine 3'5'cyclic monophosphate).

Emotional disturbance was assessed in a group of women in the first few days following childbirth and again 2 months and 1 year following childbirth; the clinical features are described. Variables such as social class, age and parity were not related to the level of emotional disturbance, but a history of marital problems, sexual difficulties, poor relationships with immediate family or disrupted family relationships in childhood were so related. Twenty-four hour urinary excretion of cyclic AMP (adenosine 3'5' cyclic monophosphate) was estimated in the same group of women on 2 occasions in the week following childbirth and again 2-3 months later in approximately one third of the original sample. Excretion of cyclic AMP in the few days following delivery was elevated compared with excretion 2-3 months later, and there was a significant rise in urinary excretion of cyclic AMP between the 1st and 2nd urine collections. Those women showing most emotional disturbance on the 3rd day after delivery and women indicating most mood change in the direction of becoming elated had the highest levels of cyclic AMP in the 2nd urine collection.

[Proteinuria in the nephropathy of pregnancy and posttoxicosis renal lesion]. / Vurkhu proteinuriia pri nefropatiiata na bremennostta i sledtoksikoznoto bubrechno uvrezhdane.

Proteinuria was studied in 110 females - 28 pregnant with nephropathy of pregnancy with primary late toxicosis and 82 with past history of the disease with a residual proteinuria after childbirth. Selective type proteinuria was more often found both in pregnant women and in those with a past history of nephropathy. The relative share of the pregnant with non-selective proteinuria is considerably greater. After childbirth, in parallel with the decrease of proteinuria quantity, the non-selective one turns to selective in the majority of the cases. The quantity of the excreted proteins, in the urine, of patients with confirmed glomerular lesions, shows no tendency to decrease. The absence of dynamics in proteinuria quantity and its non-selectivity provides grounds to suspect a deeper lesion of the renal filter, retaining the involution of the morbid process and a tendency to its chronification.