Risk Assessment Model for Postpartum Venous Thromboembolism Prevention in Patients with Systemic Lupus Erythematosus.

OBJECTIVE: This article assesses the application of the Royal College of Obstetricians and Gynaecologists (RCOG) venous thromboembolism (VTE) risk model on a cohort of postpartum patients with a history of systemic lupus erythematosus (SLE). STUDY DESIGN: This is a secondary analysis of an ongoing patient registry of women with SLE from 2016 to 2022. There were 49 SLE patients with 55 pregnancies using the Definitions of Remission in SLE (DORIS) criteria to determine SLE disease activity. RCOG risk assessment model scoring was calculated for each patient prior to and after delivery. The primary outcome was the qualification of "active SLE" by standard rheumatologic criteria and assessment of recommendations for VTE prophylaxis based on RCOG VTE risk assessment scoring. Data were analyzed using Fisher's exact test, chi-square test, and Mann-Whitney U test with significance defined as p < 0.05. RESULTS: In the study cohort, 34 pregnancies (61.8%) were in DORIS remission at delivery. Twenty-one pregnancies (38.2%) were not and scored 3 points on the RCOG VTE risk model. Of these pregnancies, only 19% (n = 4) were recommended for VTE prophylaxis by the obstetrical provider despite RCOG score ≥3. Only 35.7% (n = 5) of pregnancies in DORIS remission, but with 3 points for non-SLE-related VTE risk factors (n = 14), were recommended for VTE prophylaxis. Of the 20 pregnancies in remission with an RCOG score < 3 after assessing all risk factors, 15% (n = 3) were nevertheless recommended for VTE prophylaxis. No patients had a postpartum VTE regardless of therapy. CONCLUSION: These data reveal a need to improve upon providing postpartum VTE prophylaxis to SLE patients not in remission while also recognizing a diagnosis of SLE alone should not equate with active disease. Moreover, SLE patients in remission may still warrant VTE prophylaxis if other non-SLE-related risk factors are present. KEY POINTS: · Those with SLE are at increased risk for VTE postpartum.. · VTE prophylaxis should be instituted when clinically appropriate.. · Caution should be exercised in broadly assigning disease activity for SLE diagnosis only.. · This study supports VTE prophylaxis use in postpartum patients with SLE..

Venous thromboembolism prophylaxis for women at risk during pregnancy and the early postnatal period.

BACKGROUND: Venous thromboembolism (VTE), although rare, is a major cause of maternal mortality and morbidity. Some women are at increased risk of VTE during pregnancy and the early postnatal period (e.g. caesarean section, family history of VTE, or thrombophilia), and so prophylaxis may be considered. As some methods of prophylaxis carry risks of adverse effects, and risk of VTE is often low, benefits of thromboprophylaxis may be outweighed by harms. OBJECTIVES: To assess the effects of thromboprophylaxis during pregnancy and the early postnatal period on the risk of venous thromboembolic disease and adverse effects in women at increased risk of VTE. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 October 2019). In addition, we searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) for unpublished, planned and ongoing trial reports (18 October 2019). SELECTION CRITERIA: Randomised trials comparing one method of thromboprophylaxis with placebo or no treatment, or two (or more) methods of thromboprophylaxis. DATA COLLECTION AND ANALYSIS: At least two review authors assessed trial eligibility, extracted data, assessed risk of bias, and judged certainty of evidence for selected critical outcomes (using GRADE). We conducted fixed-effect meta-analysis and reported data (all dichotomous) as summary risk ratios (RRs) with 95% confidence intervals (CIs). MAIN RESULTS: Twenty-nine trials (involving 3839 women), overall at moderate to high risk of bias were included. Trials were conducted across the antenatal, peripartum and postnatal periods, with most in high-income countries. Interventions included types and regimens of heparin (low molecular weight heparin (LMWH) and unfractionated heparin (UFH)), hydroxyethyl starch (HES), and compression stockings or devices. Data were limited due to a small number of trials in comparisons and/or few or no events reported. All critical outcomes (assessed for comparisons of heparin versus no treatment/placebo, and LMWH versus UFH) were considered to have very low-certainty evidence, downgraded mainly for study limitations and imprecise effect estimates.  Maternal death was not reported in most studies. Antenatal (± postnatal) prophylaxis For the primary outcomes symptomatic thromboembolic events pulmonary embolism (PE) and/or deep vein thrombosis (DVT), and the critical outcome of adverse effects sufficient to stop treatment, the evidence was very uncertain.  Symptomatic thromboembolic events: - heparin versus no treatment/placebo (RR 0.39; 95% CI 0.08 to 1.98; 4 trials, 476 women; very low-certainty evidence); - LMWH versus UFH (RR 0.47; 95% CI 0.09 to 2.49; 4 trials, 404 women; very low-certainty evidence); Symptomatic PE: - heparin versus no treatment/placebo (RR 0.33; 95% CI 0.02 to 7.14; 3 trials, 187 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 287 women); Symptomatic DVT: - heparin versus no treatment/placebo (RR 0.33; 95% CI 0.04 to 3.10; 4 trials, 227 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 287 women); Adverse effects sufficient to stop treatment: - heparin versus no treatment/placebo (RR 0.49; 95% CI 0.05 to 5.31; 1 trial, 139 women; very low-certainty evidence); - LMWH versus UFH (RR 0.07; 95% CI 0.01 to 0.54; 2 trials, 226 women; very low-certainty evidence). Peripartum/postnatal prophylaxis Vaginal or caesarean birth When UFH and no treatment were compared, the effects on symptomatic thromboembolic events (RR 0.16; 95% CI 0.02 to 1.36; 1 trial, 210 women; very low-certainty evidence), symptomatic PE (RR 0.16; 95% CI 0.01 to 3.34; 1 trial, 210 women; very low-certainty evidence), and symptomatic DVT  (RR 0.27; 95% CI 0.03 to 2.55; 1 trial, 210 women; very low-certainty evidence) were very uncertain.  Maternal death and adverse effects sufficient to stop treatment were not reported. Caesarean birth Symptomatic thromboembolic events: - heparin versus no treatment/placebo (RR 1.30; 95% CI 0.39 to 4.27; 4 trials, 840 women; very low-certainty evidence); - LMWH versus UFH (RR 0.33; 95% CI 0.01 to 7.99; 3 trials, 217 women; very low-certainty evidence); Symptomatic PE: - heparin versus no treatment/placebo (RR 1.10; 95% CI 0.25 to 4.87; 4 trials, 840 women; very low-certainty evidence); - LMWH versus UFH (no events; 3 trials, 217 women);  Symptomatic DVT: - heparin versus no treatment/placebo (RR 1.30; 95% CI 0.24 to 6.94; 5 trials, 1140 women; very low-certainty evidence); LMWH versus UFH (RR 0.33; 95% CI 0.01 to 7.99; 3 trials, 217 women; very low-certainty evidence); Maternal death: - heparin versus placebo (no events, 1 trial, 300 women); Adverse effects sufficient to stop treatment: - heparin versus placebo (no events;  1 trial, 140 women). Postnatal prophylaxis No events were reported for LMWH versus no treatment/placebo for: symptomatic thromboembolic events, symptomatic PE and symptomatic DVT (all 2 trials, 58 women), or maternal death (1 trial, 24 women). Adverse effects sufficient to stop treatment were not reported. We were unable to conduct subgroup analyses due to lack of data. Sensitivity analysis including the nine studies at low risk of bias did not impact overall findings. AUTHORS' CONCLUSIONS: The evidence is very uncertain about benefits and harms of VTE thromboprophylaxis in women during pregnancy and the early postnatal period at increased risk of VTE. Further high-quality very large-scale randomised trials are needed to determine effects of currently used treatments in women with different VTE risk factors. As sufficiently large definitive trials are unlikely to be funded, secondary data analyses based on high-quality registry data are important.

Postpartum Stanford type B aortic dissection in a woman with Loeys-Dietz syndrome who underwent a prophylactic aortic root replacement before conception: A case report.

OBJECTIVE: Loeys-Dietz syndrome (LDS) is associated with a higher risk of aortic dissections (ADs) during pregnancy and postpartum. However, there is limited evidence about the perinatal management of LDS patients who have undergone prophylactic aortic root replacements (ARRs) before conception. CASE REPORT: We present the case of a 28-year-old nulliparous pregnant woman with LDS with a pathogenic variant within exon 5 of TGFBR2 (c.1379G > T, p.[Arg460Leu]), who underwent an ARR at 20 years of age. Cardiac echocardiography did not show any significant changes in the aorta during pregnancy, and her blood pressure remained normal. She had a cesarean section at 37 weeks of gestation. She developed an acute Stanford type B AD extending from the aortic arch to the infrarenal aorta 8 days postpartum and underwent a total arch replacement. CONCLUSION: This case report suggests that patients with LDS after prophylactic ARRs still possess a risk for Stanford type B ADs.

The effects of vitamin D supplementation on glycemic control and maternal-neonatal outcomes in women with established gestational diabetes mellitus: A systematic review and meta-analysis.

BACKGROUND & AIMS: Gestational Diabetes Mellitus (GDM) is associated with a well-documented range of adverse pregnancy outcomes. The present meta-analysis was conducted to evaluate the effects of vitamin D supplementation on glycemic control and maternal-neonatal outcomes in women with established GDM. METHODS: Published literature was retrieved and screened from PubMed, Embase, Web of Science, CNKI (China National Knowledge Infrastructure), Wanfang, and Cochrane Center Register of Controlled Trails up to May 2020. RCTs of vitamin D supplementation on pregnant women with GDM were included. RESULTS: 19 RCTs (1550 participants) were eligible for meta-analyses. Overall, vitamin D supplementation significantly reduced serum fasting plasma glucose (FPG) (MD: -10.20 mg/dL, 95%CI: -13.43 to -6.96), insulin concentration (MD: -5.02 µIU/mL, 95%CI: -6.83 to -3.20) and the homeostasis model assessment of insulin resistance (HOMA-IR) (MD:-1.06, 95%CI: -1.40 to -0.72) in women with GDM. In addition, vitamin D supplementation in pregnant women with GDM significantly reduced adverse maternal outcomes including cesarean section (RR: 0.75, 95%CI: 0.63 to 0.89), maternal hospitalization (RR: 0.13, 95%CI: 0.02 to 0.98) and postpartum hemorrhage (RR: 0.47, 95%CI: 0.22 to 1.00). Several adverse neonatal complications including neonatal hyperbilirubinemia (RR: 0.47, 95%CI: 0.33 to 0.67), giant children (RR: 0.58, 95%CI: 0.38 to 0.89), polyhydramnios (RR: 0.42, 95% CI: 0.24 to 0.72), fetal distress (RR: 0.46, 95%CI: 0.24 to 0.90) and premature delivery (RR: 0.43, 95% CI: 0.26 to 0.72) were also significantly reduced. CONCLUSIONS: This meta-analysis suggested that supplementation of GDM women with vitamin D may lead to an improvement in glycemic control and reduction of adverse maternal-neonatal outcomes.

Creencias y prácticas alimentarias en embarazo y puerperio: aplicación del Modelo de Tradiciones de Salud / Beliefs and dietary practices in pregnancy and the puerperium: application of the Health Traditions Model

OBJETIVO: Describir las creencias y prácticas culturales relacionadas con la alimentación durante el embarazo y puerperio en mujeres adultas (mayores de 60 años) en dos culturas diferentes, aplicando el Modelo de Tradiciones de Salud. MÉTODO: Se llevó a cabo un estudio cualitativo. Participaron 16 mujeres residentes durante su embarazo/parto/puerperio en un área rural de Braga (Portugal), o León (España). La técnica de recogida de información fue la entrevista semiestructurada. Se hizo un análisis de contenido, siguiendo el Modelo de Tradiciones de Salud. RESULTADOS: Se identificaron creencias y prácticas relacionadas con la alimentación, encaminadas a proteger, mantener y recuperar la salud de la madre/recién nacido, desde la esfera física/mental/espiritual (9 dimensiones interrelacionadas). CONCLUSIÓN: Se describieron creencias y prácticas alimentarias en embarazo/puerperio de mujeres mayores, constatando el papel de la cultura en las mismas. Se consideraron 9 dimensiones interrelacionadas, y el rol relevante de familiares/allegadas. Estos datos pueden ayudarnos a planificar acciones de salud maternal en la actualidad, participativas (familia/comunidad), corregir ciertas prácticas, y proporcionar cuidados congruentes con la cultura de las mujeres. Ello puede ayudar a transformar creencias, o valores y actitudes que incardinan una determinada forma cultural en la enfermería

OBJECTIVE: To describe the cultural beliefs and practices related to food during pregnancy and the puerperium in adult women (over 60 years old) in two different cultures by applying the Health Traditions Model. METHOD: A qualitative study was carried out with the participation of 16 women resident during their pregnancy / childbirth / puerperium in a rural area of Braga (Portugal), and León (Spain). The information collection technique was the semi-structured interview. A content analysis was made, following the Health Traditions Model. RESULTS: Beliefs and dietary practices related to feeding were identified, aimed at protecting, maintaining and recovering the health of the mother / newborn, from the physical / mental / spiritual sphere (9 interrelated dimensions). CONCLUSION: Eating beliefs and practices in pregnancy / puerperium of older women were described, confirming the role of culture in them. 9 interrelated dimensions were considered, as well as the relevant role of family / relatives. These data can help us plan for current, participatory (family / community) maternal health actions, correct certain practices, and provide care consistent with the culture of women. This can help transform beliefs, or values and attitudes that embody a certain cultural form in nursing

Regular antenatal exercise including pelvic floor muscle training reduces urinary incontinence 3 months postpartum-Follow up of a randomized controlled trial.

INTRODUCTION: Urinary incontinence is a frequently reported condition among women with pregnancy and delivery as established risk factors. The aims of this study were to evaluate the effect of an antenatal exercise program including pelvic floor muscle training on postpartum urinary incontinence, and to explore factors associated with urinary incontinence three months postpartum. MATERIAL AND METHODS: This is a short-term follow-up and secondary analysis of a randomized controlled trial conducted at two Norwegian University Hospitals including healthy, pregnant women aged >18 years with a singleton live fetus. Women in the exercise group received a 12-week standardized exercise program including pelvic floor muscle training, with once weekly group exercise classes led by a physiotherapist and twice weekly home exercise sessions. The controls received standard antenatal care. Data were obtained from questionnaires answered in pregnancy weeks 18-22, and three months postpartum. Urinary incontinence prevalence in the exercise and control groups was compared, and multivariable logistic regression analyses were applied. Urinary incontinence prevalence three months postpartum was assessed by the Sandvik severity index. RESULTS: Among the 722 (84%) women who responded three months postpartum, significantly fewer women in the exercise group (29%) reported urinary incontinence compared with the standard antenatal care group (38%, P = .01). Among women who were incontinent at baseline, 44% and 59% (P = .014) were incontinent at three months postpartum in the exercise and control groups, respectively. Urinary incontinence three months postpartum was associated with age (OR 1.1, 95% CI 1.0-1.1), experiencing urinary incontinence in late pregnancy (OR 3.6, 95% CI 2.3-5.9), birthweight ≥4000 g (OR 1.8, 95% CI 1.2-2.8), and obstetric anal sphincter injuries (OR 2.6, 95% CI 1.1-6.1). Cesarean section significantly reduced the risk of urinary incontinence three months postpartum compared with spontaneous vaginal delivery (OR 0.2, 95% CI 0.1-0.5). CONCLUSIONS: A moderate-intensity exercise program including pelvic floor muscle training reduced prevalence of urinary incontinence 3 months postpartum in women who were incontinent at baseline.

Society for Maternal-Fetal Medicine Consult Series #55: Counseling women at increased risk of maternal morbidity and mortality.

Women should be provided with evidence-based information when considering options for contraception and pregnancy management. When counseling about health conditions and available treatments, healthcare practitioners should employ strategies that encourage the incorporation of informed patient preferences into a shared decision-making process with the patient. To optimize the health of women at risk of experiencing adverse health outcomes during or after pregnancy, counseling should be a continuous process throughout the reproductive life course. The purpose of this Consult is to provide guidance for all healthcare practitioners about counseling reproductive-aged women who may be at high risk of experiencing maternal morbidity or mortality.

Venous thromboembolism risk and prophylaxis in hospitalized obstetric patients at a tertiary hospital in Accra, Ghana: A comparative cross-sectional study.

OBJECTIVE: To determine the prevalence of venous thromboembolism risk and thromboprophylaxis among obstetric inpatients, comparing prenatal and postnatal women. METHODS: We assessed 546 obstetric inpatients at the Korle-Bu Teaching Hospital for the prevalence study. Out of this number, 223 were recruited, comprising 111 prenatal and 112 postnatal mothers. A structured interviewer-administered questionnaire was used to obtain data on participants' venous thromboembolism risk, which was categorized into high, intermediate, and low using the Royal College of Obstetricians and Gynaecologists guidelines. Data on thromboprophylaxis were also obtained and analyzed. Values were considered statistically significant at p < 0.05. RESULTS: Overall venous thromboembolism risk among the study population was 82/223 (36.8%). All patients at high risk were prenatal, 59/112 (52.7%) of postnatal mothers were at intermediate risk, compared with 20/111 (18.0%) of prenatal women (p < 0.001). Prevalence of thromboprophylaxis was 5/82 (6.1%). All prenatal high-risk patients received thromboprophylaxis, whereas only 2/20 (10.0%) of women with intermediate risk received thromboprophylaxis. The incidence of venous thromboembolism was 3/546 (0.6%) in the obstetric inpatients. CONCLUSION: Our study found a high prevalence of venous thromboembolism risk among obstetric inpatients at the Korle-Bu Teaching Hospital. However, thromboprophylaxis was low. Further research is needed to audit recent practice of thromboprophylaxis and perinatal outcome.

Prevent postpartum blues with the implementation of breastfeeding father education model to increase the frequency of breastfeeding in mothers: A systematic review

Objective: To find out if the breastfeeding father education model can increase exclusive breastfeeding in mothers to prevent the occurrence of postpartum blues. Methods: This study uses literature review design, articles collected using search engines such as PubMed, Elsevier, Scinapse, Plos One, and Google Scholar. We identified journals based on the PRISMA 2015 Guidelines with a total of n = 5690 and obtained the number of journals reviewed n = 33. Results: The father's support is believed to have influenced the mother's decision to start and maintain breastfeeding. Father education is proven to increase breastfeeding with a value of p (0.001) < 0.05. In addition, support from husbands is also classified as sufficient (54%) in lowering anxiety levels in mothers with spearman's test results p = 0.48 or <0.05. Conclusions: Providing an education model of breastfeeding father can increase the exclusive breastfeeding by the mother to prevent the occurrence of postpartum blues. (AU)

＜Editors' Choice＞ Factors influencing utilization of postnatal care visits in Afghanistan.

The World Health Organization (WHO) defines the postnatal period as the first six weeks (42 days) after delivery and recommends four postnatal care (PNC) visits for women giving birth to a child to enable early detection and treatment of complications. However, a low utilization of PNC visits by Afghan women has contributed to a relatively high maternal mortality in Afghanistan. This study aimed to identify factors influencing the utilization of PNC visits among Afghan women by sampling nationally representative data from Afghanistan Demographic and Health Survey (AfDHS), 2015. The logistic model was used to measure the adjusted odds of utilizing PNC services among women, with a 95% confidence interval (95% CI) and a p-value of <0.05 for statistical significance. The study found that the utilization of PNC visits in Afghanistan is low; among 8,581 women (44%) who utilized PNC visits and 10,924 women (56%) who didn't, the women's age, place of residence, parity, education, occupation, number of antenatal care (ANC) visits, place of delivery, exposure to public media, the woman's role in decision making and needing a permission to seek healthcare were found to be associated with the level of utilization of PNC visits. Based on the study results, health promotion interventions are recommended to increase the utilization of PNC visits.

Detection and Prevention of Postpartum Posttraumatic Stress Disorder: A Call to Action.

The rising maternal mortality rate has drawn increased focus to postpartum depression. However, other mental health conditions, such as birth-related postpartum traumatic stress disorder, have not garnered the same level of attention. The majority of research about postpartum posttraumatic stress disorder (PTSD) is published in journals focused on psychiatry, psychology, and nursing, where this phenomenon is well recognized. In contrast, there is a lack of awareness among most obstetricians. Consequently, few recommendations are available to guide clinical practice. This commentary will present a clinical vignette, provide background that is key to the detection of PTSD, explore available data on postpartum PTSD, and provide recommendations for recognition and prevention of this disorder.

Interventions for preventing postpartum constipation.

BACKGROUND: Postpartum constipation, with symptoms, such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones, and haematinics used in pregnancy can increase the risk of postpartum constipation. Eating a high-fibre diet and increasing fluid intake are usually encouraged. Although laxatives are commonly used in relieving constipation, the effectiveness and safety of available interventions for preventing postpartum constipation should be ascertained. This is an update of a review first published in 2015. OBJECTIVES: To evaluate the effectiveness and safety of interventions for preventing postpartum constipation. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, and two trials registers ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 October 2019), and screened reference lists of retrieved trials. SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) comparing any intervention for preventing postpartum constipation versus another intervention, placebo, or no intervention in postpartum women. Interventions could include pharmacological (e.g. laxatives) and non-pharmacological interventions (e.g. acupuncture, educational and behavioural interventions). Quasi-randomised trials and cluster-RCTs were eligible for inclusion; none were identified. Trials using a cross-over design were not eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the results of the search to select potentially relevant trials, extracted data, assessed risk of bias, and the certainty of the evidence, using the GRADE approach. We did not pool results in a meta-analysis, but reported them per study. MAIN RESULTS: We included five trials (1208 postpartum mothers); three RCTs and two quasi-RCTs. Four trials compared a laxative with placebo; one compared a laxative plus a bulking agent versus the same laxative alone, in women who underwent surgical repair of third degree perineal tears. Trials were poorly reported, and four of the five trials were published over 40 years ago. We judged the risk of bias to be unclear for most domains. Overall, we found a high risk of selection and attrition bias. Laxative versus placebo We included four trials in this comparison. Two of the trials examined the effects of laxatives that are no longer used; one has been found to have carcinogenic properties (Danthron), and the other is not recommended for lactating women (Bisoxatin acetate); therefore, we did not include their results in our main findings. None of the trials included in this comparison assessed our primary outcomes: pain or straining on defecation, incidence of postpartum constipation, or quality of life; or many of our secondary outcomes. A laxative (senna) may increase the number of women having their first bowel movement within 24 hours after delivery (risk ratio (RR) 2.90, 95% confidence interval (CI) 2.24 to 3.75; 1 trial, 471 women; low-certainty evidence); may have little or no effect on the number of women having their first bowel movement on day one after delivery (RR 0.94, 95% CI 0.72 to 1.22; 1 trial, 471 women; very low-certainty evidence); may reduce the number of women having their first bowel movement on day two (RR 0.23, 95% CI 0.11 to 0.45; 1 trial, 471 women; low-certainty evidence); and day three (RR 0.05, 95% CI 0.00 to 0.89; 1 trial, 471 women; low-certainty evidence); and may have little or no effect on the number of women having their first bowel movement on day four after delivery (RR 0.22, 95% CI 0.03 to 1.87; 1 trial, 471 women; very low-certainty evidence), but some of the evidence is very uncertain. Adverse effects were poorly reported. Low-certainty evidence suggests that the laxative (senna) may increase the number of women experiencing abdominal cramps (RR 4.23, 95% CI 1.75 to 10.19; 1 trial, 471 women). Very low-certainty evidence suggests that laxatives taken by the mother may have little or no effect on loose stools in the baby (RR 0.62, 95% CI 0.16 to 2.41; 1 trial, 281 babies); or diarrhoea (RR 2.46, 95% CI 0.23 to 26.82; 1 trial, 281 babies). Laxative plus bulking agent versus laxative only Very low-certainty evidence from one trial (147 women) suggests no evidence of a difference between these two groups of women who underwent surgical repair of third degree perineal tears; only median and range data were reported. The trial also reported no evidence of a difference in the incidence of postpartum constipation (data not reported), but did not report on quality of life. Time to first bowel movement was reported as a median (range); very low-certainty evidence suggests little or no difference between the two groups. A laxative plus bulking agent may increase the number of women having any episode of faecal incontinence during the first 10 days postpartum (RR 1.81, 95% CI 1.01 to 3.23; 1 trial, 147 women; very low-certainty evidence). The trial did not report on adverse effects of the intervention on babies, or many of our secondary outcomes. AUTHORS' CONCLUSIONS: There is insufficient evidence to make general conclusions about the effectiveness and safety of laxatives for preventing postpartum constipation. The evidence in this review was assessed as low to very low-certainty evidence, with downgrading decisions based on limitations in study design, indirectness and imprecision. We did not identify any trials assessing educational or behavioural interventions. We identified four trials that examined laxatives versus placebo, and one that examined laxatives versus laxatives plus stool bulking agents. Further, rigorous trials are needed to assess the effectiveness and safety of laxatives during the postpartum period for preventing constipation. Trials should assess educational and behavioural interventions, and positions that enhance defecation. They should report on the primary outcomes from this review: pain or straining on defecation, incidence of postpartum constipation, quality of life, time to first bowel movement after delivery, and adverse effects caused by the intervention, such as: nausea or vomiting, pain, and flatus.

Recombinant protein subunit vaccine reduces puerperal metritis incidence and modulates the genital tract microbiome.

The objective of this study was to evaluate the efficacy of 3 vaccine formulations containing proteins (FimH, leukotoxin, and pyolysin), inactivated whole cells (Escherichia coli, Fusobacterium necrophorum, and Trueperella pyogenes), or both, in the prevention of postpartum uterine diseases. A randomized clinical trial was conducted at a commercial dairy farm; 800 heifers were assigned into 1 of 4 different treatment groups: control, vaccine 1 (bacterin and subunit proteins), vaccine 2 (bacterin), and vaccine 3 (recombinant subunit proteins), and each heifer received a subcutaneous injection of its respective treatment at 240 ± 3 and 270 ± 3 d of gestation. Vaccination significantly reduced the incidence of puerperal metritis when compared with control (9.1% vs. 14.9%, respectively; odds ratio 0.51). Additionally, vaccine 3 was found to reduce the incidence of puerperal metritis when compared with the control (8.0% vs. 14.9%, respectively; odds ratio 0.46). Reproduction was improved for metritic cows that were vaccinated, and the effect was stronger for cows that were treated with vaccine 3. In general, vaccination decreased the total vaginal bacterial load and decreased the vaginal load of F. necrophorum by 9 d in milk. Vaccination reduced the prevalence of puerperal metritis in the first lactation of dairy cows, leading to less metritic disease and improved reproduction.

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women.

BACKGROUND: About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017. OBJECTIVES: To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies. SELECTION CRITERIA: We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment). DATA COLLECTION AND ANALYSIS: We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE. MAIN RESULTS: We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. AUTHORS' CONCLUSIONS: This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.

Prenatal high-low impact exercise program supported by pelvic floor muscle education and training decreases the life impact of postnatal urinary incontinence: A quasiexperimental trial.

BACKGROUND: Pregnancy and high impact exercise may cause postnatal urinary incontinence. We aimed to evaluate the life impact of postnatal urinary incontinence in women attending prenatal, high-low impact exercise program, supported by pelvic floor muscle education and training, in comparison to controls. METHODS: It was a quasiexperimental trial among 260 postpartum Caucasian women (age 29 ±â€Š4 years; mean ±â€Šstandard deviation). The training group (n = 133) attended a high-low impact exercise and educational program from the 2nd trimester of pregnancy until birth, 3 times a week. We educated this group to contract and relax pelvic floor muscles with surface electromyography biofeedback and instructed how to exercise postpartum. Control women (n = 127) did not get any intervention. All women reported on the life impact of urinary incontinence 2 months and 1 year postpartum using the Incontinence Impact Questionnaire (IIQ). RESULTS: Training group started regular pelvic floor muscle exercises substantially earlier postpartum than controls (P < .001). Significantly less training women reported the life impact of urinary incontinence both 2 months (P = .03) and 1 year postpartum (P = .005). Two months after birth, for the symptomatic women the IIQ scores were significantly lower in the training than in the control women (median [Me] = 9.4 vs Me = 18.9; P = .002). Between the 1st and 2nd assessments the number of women affected by incontinence symptoms decreased by 38% in the training group and by 20% in the controls. CONCLUSION: High-low impact activities supported by pelvic floor muscle exercises and education should be promoted among pregnant, physically active women. Such activities may help women to continue high-intensity exercise with the simultaneous prevention of postnatal urinary incontinence.Thy study was registered at ISRCTN under the title "Pelvic floor muscle training with surface electromyography" (DOI 10.1186/ISRCTN92265528).

Venous thromboembolism prophylaxis of the obese postpartum patient: A cross-sectional study.

BACKGROUND: Obesity increases risk of venous thromboembolism (VTE) in obstetric patients regardless of delivery mode and for up to six weeks postpartum. AIM: This study aimed to examine postpartum pharmacological VTE prophylaxis practices for obese women at an Australian tertiary referral hospital. MATERIALS AND METHODS: Medical records were retrieved for obese obstetric patients who delivered during May 2016-May 2017. Records were examined for demographic data, VTE risk factors, and LMWH (low-molecular-weight heparin) use. Due to lack of specific Australian or local guidelines, practice was evaluated using recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG-UK). Patients with BMI (body mass index) <30, incomplete/unavailable medical records, and those discharged from other health services were excluded. RESULTS: One hundred and eight postpartum patients (70 caesareans, 38 vaginal deliveries) with a BMI ≥ 30 kg/m2 were reviewed. Of these patients, 53 (49.1%) had a BMI ≥ 40 kg/m2 . Ninety-eight of 108 (90.7%) patients had ≥2 VTE risk factors including a BMI ≥ 30 kg/m2 . One hundred and three of 108 (95.4%) patients were indicated for postpartum VTE prophylaxis with LMWH, and 77 of 103 (74.8%) patients received it. Three of five patients meeting criteria for ≥6 weeks of LMWH thromboprophylaxis had it prescribed. Of the 72 patients whose weight exceeded 90 kg and who also received LMWH, 32 (44.4%) were prescribed a weight-adjusted dose. CONCLUSION: VTE prophylaxis practices using LMWH in obese postpartum patients, including weight-adjusting doses and extended-course prescribing, appear variable. Limited literature, recommendation discrepancies, and varied awareness of recommendations may be contributing factors. Further education and research regarding this high-risk cohort are warranted.

Increased dietary calcium inclusion in fully acidified prepartum diets improved postpartum uterine health and fertility when fed to Holstein cows.

The objective of this study was to determine the effects of prepartum negative dietary cation-anion difference diet (DCAD) fed at two dietary Ca inclusion rates on postpartum uterine health and ovulation dynamics of multiparous Holstein cows (n = 76). Treatments began at 28 days before expected calving until parturition and were: CON: DCAD = +6 mEq/100g of DM with low dietary Ca (46.2 ± 15.2 g Ca/d; 0.4% DM; n = 26); ND: DCAD = -24 mEq/100g of DM with low dietary Ca (44.1 ±â€¯16.1 Ca/d; 0.4% DM; n = 24); NDCA: DCAD = -24 mEq/100g of DM with high dietary Ca (226.6 ±â€¯96.0 g Ca/d; 2.0% DM; n = 26). Vaginal discharge was evaluated through the fresh period via Metricheck (MC) for presence of purulent material. Polymorphonuclear (PMN) cell concentration in the uterus was evaluated at 15 and 30 days relative to calving (DRC). Endometrial tissue was harvested at 30 DRC for glandular morphology, presence of tight-junctions and adheren-junctions proteins, as well as assessment of superoxide dismutase (SOD) and glutathione peroxidase (GPX) activity. Blood plasma and serum samples were harvested in the prepartum and postpartum phase and were assessed for concentrations of lipopolysaccharide binding protein (LBP), serum amyloid A (SAA), and haptoglobin (HP). Ovarian dynamics were assessed through the fresh period until first timed artificial insemination (TAI). Cows fed CON had a lower MC score (P = 0.06) than the average of cows fed ND and cows fed NDCA. Cows fed ND had a higher MC score than cows fed NDCA. Cows fed NDCA had greater uterine gland epithelial height (P = 0.02) than cows fed ND. Cows fed NDCA also had a greater number of epithelial cells per gland (P = 0.05) than cows fed ND. Cows fed NDCA had greater intensity of occludin expression (P = 0.15) than cows fed ND. Cows fed NDCA had increased activity of SOD (P = 0.05) and decreased activity of GPX (P < 0.001) than cows fed ND. Cows fed ND had higher plasma HP concentrations than cows fed NDCA in the prepartum (P = 0.01) and post-partum (P = 0.03) periods. Cows fed ND and NDCA had lower (P = 0.01) postpartum plasma HP concentration than cows fed CON. In conclusion, cows fed NDCA had an improved uterine environment most likely due to alleviation of oxidative stress, an enhanced immune response to parturition and uterine discharge comparable to cows fed CON.