Cardiac Remodeling After Hypertensive Pregnancy Following Physician-Optimized Blood Pressure Self-Management: The POP-HT Randomized Clinical Trial Imaging Substudy.

BACKGROUND: Hypertensive pregnancy disorders are associated with adverse cardiac remodeling, which can fail to reverse in the postpartum period in some women. The Physician-Optimized Postpartum Hypertension Treatment trial demonstrated that improved blood pressure control while the cardiovascular system recovers postpartum associates with persistently reduced blood pressure. We now report the effect on cardiac remodeling. METHODS: In this prospective, randomized, open-label, blinded end point trial, in a single UK hospital, 220 women were randomly assigned 1:1 to self-monitoring with research physician-optimized antihypertensive titration or usual postnatal care from a primary care physician and midwife. Participants were 18 years of age or older, with preeclampsia or gestational hypertension, requiring antihypertensives on hospital discharge postnatally. Prespecified secondary cardiac imaging outcomes were recorded by echocardiography around delivery, and again at blood pressure primary outcome assessment, around 9 months postpartum, when cardiovascular magnetic resonance was also performed. RESULTS: A total of 187 women (101 intervention; 86 usual care) underwent echocardiography at baseline and follow-up, at a mean 258±14.6 days postpartum, of which 174 (93 intervention; 81 usual care) also had cardiovascular magnetic resonance at follow-up. Relative wall thickness by echocardiography was 0.06 (95% CI, 0.07-0.05; P<0.001) lower in the intervention group between baseline and follow-up, and cardiovascular magnetic resonance at follow-up demonstrated a lower left ventricular mass (-6.37 g/m2; 95% CI, -7.99 to -4.74; P<0.001), end-diastolic volume (-3.87 mL/m2; 95% CI, -6.77 to -0.98; P=0.009), and end-systolic volume (-3.25 mL/m2; 95% CI, 4.87 to -1.63; P<0.001) and higher left and right ventricular ejection fraction by 2.6% (95% CI, 1.3-3.9; P<0.001) and 2.8% (95% CI, 1.4-4.1; P<0.001), respectively. Echocardiography-assessed left ventricular diastolic function demonstrated a mean difference in average E/E' of 0.52 (95% CI, -0.97 to -0.07; P=0.024) and a reduction in left atrial volumes of -4.33 mL/m2 (95% CI, -5.52 to -3.21; P<0.001) between baseline and follow-up when adjusted for baseline differences in measures. CONCLUSIONS: Short-term postnatal optimization of blood pressure control after hypertensive pregnancy, through self-monitoring and physician-guided antihypertensive titration, associates with long-term changes in cardiovascular structure and function, in a pattern associated with more favorable cardiovascular outcomes. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04273854.

Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association.

Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.

Within-individual relationships between mother-to-infant bonding and postpartum depressive symptoms: a longitudinal study.

BACKGROUND: Although the importance of the dynamic intra-individual relationship between mother-to-infant bonding and postpartum depressive symptoms has been widely recognized, the complex interplay between them is not well understood. Furthermore, the potential role of prenatal depressive symptoms and infant temperament in this relationship remains unclear. This study aims to examine the bidirectional influence of mother-to-infant bonding on postpartum depressive symptoms within individuals and to elucidate whether prenatal depressive symptoms and infant temperament would influence deviations from stable individual states. METHODS: Longitudinal data were collected from 433 women in early pregnancy. Of these, 360 participants completed the main questionnaires measuring impaired mother-to-infant bonding and postpartum depressive symptoms at least once during the postpartum period. Data were collected at early and late pregnancy and several postpartum time points: shortly after birth and at one, four, ten, and 18 months postpartum. We also assessed prenatal depressive symptoms and infant temperament. A random-intercept cross-lagged panel model was used. RESULTS: Within-individual variability in mother-to-infant bonding, especially anger and rejection, significantly predicted subsequent postpartum depressive symptoms. However, the inverse relationship was not significant. Additionally, prenatal depressive symptoms and difficult infant temperament were associated with greater within-individual variability in impaired mother-to-infant bonding and postpartum depressive symptoms. CONCLUSIONS: The present study demonstrated that the within-individual relationship between mother-to-infant bonding and postpartum depressive symptoms is likely non-bidirectional. The significance of the findings is underscored by the potential for interventions aimed at improving mother-to-infant bonding to alleviate postpartum depressive symptoms, suggesting avenues for future research and practice.

The fatigue after infusion or transfusion pilot trial and feasibility study: A three-armed randomized pilot trial of intravenous iron and blood transfusion for the treatment of postpartum anemia.

BACKGROUND: Evidence for the management of moderate-to-severe postpartum anemia is limited. A randomized trial is needed; recruitment may be challenging. STUDY DESIGN AND METHODS: Randomized pilot trial with feasibility surveys. INCLUSION: hemoglobin 65-79 g/L, ≤7 days of birth, hemodynamically stable. EXCLUSION: ongoing heavy bleeding; already received, or contraindication to intravenous (IV)-iron or red blood cell transfusion (RBC-T). Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T. PRIMARY OUTCOME: number of recruits; proportion of those approached; proportion considered potentially eligible. SECONDARY OUTCOMES: fatigue, depression, baby-feeding, and hemoglobin at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. Surveys explored attitudes to trial participation. RESULTS: Over 16 weeks and three sites, 26/34 (76%) women approached consented to trial participation, including eight (31%) Maori women. Of those potentially eligible, 26/167 (15.6%) consented to participate. Key participation enablers were altruism and study relevance. For clinicians and stakeholders the availability of research assistance was the key barrier/enabler. Between-group rates of fatigue and depression were similar. Although underpowered to address secondary outcomes, IV-iron and RBC-T compared with RBC-T were associated with higher hemoglobin concentrations at 6 (mean difference [MD] 11.7 g/L, 95% confidence interval [CI] 2.7-20.7) and 12 (MD 12.8 g/L, 95% CI 1.5-24.2) weeks, and higher ferritin concentrations at 6 weeks (MD 136.8 mcg/L, 95% CI 76.6-196.9). DISCUSSION: Willingness to participate supports feasibility for a future trial assessing the effectiveness of IV-iron and RBC-T for postpartum anemia. Dedicated research assistance will be critical to the success of an appropriately powered trial including women-centered outcomes.

Society for Maternal-Fetal Medicine Position Statement: Gun violence and pregnancy.

Position: The Society for Maternal-Fetal Medicine acknowledges gun violence as a public health crisis in the United States, with a substantial impact on pregnant and postpartum people. We recognize the urgent need for a robust, equitable, data-driven approach to mitigate the impact of access to firearms and accompanying violence on pregnant and postpartum individuals and communities. As such, the Society for Maternal-Fetal Medicine endorses the following policy principles.

Urinary incontinence increases risk of postpartum depression: systematic review and meta-analysis.

OBJECTIVE: Postpartum depression is one of the most common complications after childbearing. Urinary incontinence is a frequent symptom during pregnancy and the postnatal period, often being the first time that women experience it. This systematic review and meta-analysis aimed to synthesize the evidence on the association between urinary incontinence and postpartum depression and to assess whether this association becomes weaker at 6 months after childbirth. DATA SOURCES: MEDLINE, Embase, Cochrane Library, Web of Science, and PsycINFO were searched from inception to December 26, 2023. STUDY ELIGIBILITY CRITERIA: Cross-sectional and cohort studies addressing the association between urinary incontinence and postpartum depression were included. METHODS: Pooled odds ratios and their 95% confidence intervals, and 95% prediction intervals were estimated using a DerSimonian and Laird random-effects model for the association between urinary incontinence and postpartum depression. Subgroup analyses were conducted on the basis of time after delivery (<6 or ≥6 months). The risk of bias was assessed with the National Institutes of Health Quality Assessment Tool for Observational Cohort Studies. RESULTS: Eleven published studies were included in the systematic review and meta-analysis. Overall, the odds ratio for the association between urinary incontinence and postpartum depression was 1.45 (95% confidence interval, 1.11-1.79; 95% prediction interval, 0.49-2.40; I2=65.9%; P=.001). For the 7 cohort studies, the odds ratio was 1.63 (95% confidence interval, 1.35-1.91; 95% prediction interval, 1.14-2.13; I2=11.1%; P=.345). For the 4 cross-sectional studies, the odds ratio was 1.05 (95% confidence interval, 1.04-1.05; 95% prediction interval, 1.04-1.06; I2=0.0%; P=.413). According to the time after delivery, the odds ratio estimates for cohort studies with a postpartum period <6 months were 1.44 (95% confidence interval, 1.07-1.81; prediction interval, 0.63-2.25; I2=0.0%; P=.603) and 1.53 (95% confidence interval, 1.16-1.89; prediction interval, 0.41-2.65; I2=50.7%; P=.087) for those with a postpartum period ≥6 months. CONCLUSION: This systematic review and meta-analysis suggests that urinary incontinence may be a potential predictor of postpartum depression. Thus, it is important that health care professionals offer support and treatment options to women who experience these conditions.

Preventing posttraumatic stress disorder following childbirth: a systematic review and meta-analysis.

OBJECTIVE: Women can develop posttraumatic stress disorder in response to experienced or perceived traumatic, often medically complicated, childbirth; the prevalence of these events remains high in the United States. Currently, no recommended treatment exists in routine care to prevent or mitigate maternal childbirth-related posttraumatic stress disorder. We conducted a systematic review and meta-analysis of clinical trials that evaluated any therapy to prevent or treat childbirth-related posttraumatic stress disorder. DATA SOURCES: PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible trials published through September 2023. STUDY ELIGIBILITY CRITERIA: Trials were included if they were interventional, if they evaluated any therapy for childbirth-related posttraumatic stress disorder for the indication of symptoms or before posttraumatic stress disorder onset, and if they were written in English. METHODS: Independent coders extracted the sample characteristics and intervention information of the eligible studies and evaluated the trials using the Downs and Black's quality checklist and Cochrane's method for risk of bias evaluation. Meta-analysis was conducted to evaluate pooled effect sizes of secondary and tertiary prevention trials. RESULTS: A total of 41 studies (32 randomized controlled trials, 9 nonrandomized trials) were reviewed. They evaluated brief psychological therapies including debriefing, trauma-focused therapies (including cognitive behavioral therapy and expressive writing), memory consolidation and reconsolidation blockage, mother-infant-focused therapies, and educational interventions. The trials targeted secondary preventions aimed at buffering childbirth-related posttraumatic stress disorder usually after traumatic childbirth (n=24), tertiary preventions among women with probable childbirth-related posttraumatic stress disorder (n=14), and primary prevention during pregnancy (n=3). A meta-analysis of the combined randomized secondary preventions showed moderate effects in reducing childbirth-related posttraumatic stress disorder symptoms when compared with usual treatment (standardized mean difference, -0.67; 95% confidence interval, -0.92 to -0.42). Single-session therapy within 96 hours of birth was helpful (standardized mean difference, -0.55). Brief, structured, trauma-focused therapies and semi-structured, midwife-led, dialogue-based psychological counseling showed the largest effects (standardized mean difference, -0.95 and -0.91, respectively). Other treatment approaches (eg, the Tetris game, mindfulness, mother-infant-focused treatment) warrant more research. Tertiary preventions produced smaller effects than secondary prevention but are potentially clinically meaningful (standardized mean difference, -0.37; -0.60 to -0.14). Antepartum educational approaches may help, but insufficient empirical evidence exists. CONCLUSION: Brief trauma-focused and non-trauma-focused psychological therapies delivered early in the period following traumatic childbirth offer a critical and feasible opportunity to buffer the symptoms of childbirth-related posttraumatic stress disorder. Future research that integrates diagnostic and biological measures can inform treatment use and the mechanisms at work.

Physical job demands in pregnancy and associated musculoskeletal health and employment outcomes: a systematic review.

OBJECTIVE: A decline in musculoskeletal health during pregnancy is an underappreciated adverse outcome of pregnancy that can have immediate and long-term health consequences. High physical job demands are known risk factors for nontraumatic musculoskeletal disorders in the general working population. Evidence from meta-analyses suggest that occupational lifting and prolonged standing during pregnancy may increase risk of adverse pregnancy outcomes. This systematic review examined associations between occupational lifting or postural load in pregnancy and associated musculoskeletal disorders and related sequalae. DATA SOURCES: Five electronic databases (Medline, Embase, CINAHL, NIOSHTIC-2, and Ergonomic Abstracts) were searched from 1990 to July 2022 for studies in any language. A Web of Science snowball search was performed in December 2022. Reference lists were manually reviewed. STUDY ELIGIBILITY CRITERIA: Eligible studies reported associations between occupational lifting or postural load and musculoskeletal health or sequelae (eg, employment outcomes) among pregnant and postpartum workers. METHODS: Data were extracted using a customized form to document study and sample characteristics; and details of exposures, outcomes, covariates, and analyses. Investigators independently assessed study quality for 7 risk-of-bias domains and overall utility, with discrepant ratings resolved through discussion. A narrative synthesis was conducted due to heterogeneity. RESULTS: Sixteen studies (11 cohort studies, 2 nested case-control studies, and 3 cross-sectional studies) from 8 countries were included (N=142,320 pregnant and N=1744 postpartum workers). Limited but consistent evidence with variable quality ratings, ranging from critical concern to high, suggests that pregnant workers exposed to heavy lifting (usually defined as ≥22 lbs or ≥10 kg) may be at increased risk of functionally limiting pelvic girdle pain and antenatal leave. Moreover, reports of dose-response relationships suggest graded risk levels according to lifting frequency, ranging from 21% to 45% for pelvic girdle pain and 58% to 202% for antenatal leave. Limited but consistent evidence also suggests that postural load increases the risk of employment cessation. CONCLUSION: Limited but consistent evidence suggests that pregnant workers exposed to heavy lifting and postural load are at increased risk of pelvic girdle pain and employment cessation. Job accommodations to reduce exposure levels may promote safe sustainable employment for pregnant workers.

Genital self-image and sexual function in Iranian women from pregnancy to postpartum: a cohort study.

BACKGROUND: Genital self-image is among the factors affecting women's sexual function. AIM: The present study aimed to determine changes in the genital self-image and its relationship with women's sexual function in the third trimester of pregnancy and postpartum. METHODS: The participants of this prospective cohort study included 301 eligible pregnant women chosen through stratified random sampling with proportional allocation from comprehensive health centers in Gorgan, Iran. The Persian version of the 7-item Female Genital Self-Image Scale, the 6-item Female Sexual Function Index, and Depression Anxiety and Stress Scale 21 were filled in a self-report manner on 2 occasions: (1) 30 to 37 weeks of pregnancy and (2) 12 to 16 weeks (± 2 weeks) postpartum. Finally, the data were analyzed using SPSS 24 software. OUTCOMES: Outcomes included Female Genital Self-Image Scale and Female Sexual Function Index changes from pregnancy to postpartum according to the childbirth mode. RESULTS: The mean age of participants was 29.66 ± 5.27 years. These values for the genital self-image scores of women during pregnancy (19.18 ± 3.25) and postpartum (19.43 ± 3.57) were not significantly different (P = .30). Also, this difference was not statistically significant regarding the mode of delivery in 2 groups of women with vaginal birth (P = .62) and cesarean section (P = .14). The mean Female Sexual Function Index scores during pregnancy (15.15 ± 6.73) and postpartum (17.52 ± 6.46) were significantly different (P = .001). In addition, this difference was significant in women with vaginal birth (P = .004) and cesarean section (P = .001). CLINICAL IMPLICATIONS: Clinicians should inform women/couples about changes in female sexual function and address genital self-image as a factor involved in female sexual function during pregnancy and postpartum.Strengths and Limitations: Because the participants of this study were women in the third trimester of pregnancy, the obtained results may not be generalized to pregnant women in the first and second trimesters of pregnancy or even to different postpartum periods (ie, midterm and long term). CONCLUSION: The results showed that the female genital self-image is not significantly different during pregnancy and postpartum, or with the mode of delivery. However, the female sexual function score in postpartum is higher than in pregnancy, regardless of the mode of delivery.

CT venography for the diagnosis of postpartum venous thromboembolism: a prospective multi-center cohort study.

OBJECTIVES: To assess the role of CT venography (CTV) in the diagnosis of venous thromboembolism (VTE) during the postpartum period. MATERIALS AND METHODS: This multicenter prospective cohort study was conducted between April 2016 and April 2020 in 14 university hospitals. All women referred for CT pulmonary angiography (CTPA) for suspected pulmonary embolism (PE) within the first 6 weeks postpartum were eligible. All CTPAs were performed on multidetector CT machines with the usual parameters and followed by CTV of the abdomen, pelvis, and proximal lower limbs. On-site reports were compared to expert consensus reading, and the added value of CTV was assessed for both. RESULTS: The final study population consisted of 123 women. On-site CTPA reports mentioned PE in seven women (7/123, 5.7%), all confirmed following expert consensus reading, three involving proximal pulmonary arteries and four limited to distal arteries. Positive CTV was reported on-site in nine women, five of whom had negative and two indeterminate CTPAs, bringing the VTE detection rate to 11.4% (14/123) (95%CI: 6.4-18.4, p = 0.03). Expert consensus reading confirmed all positive on-site CTV results, but detected a periuterine vein thrombosis in an additional woman who had a negative CTPA, increasing the VTE detection rate to 12.2% (15/123) (95%CI: 7.0-19.3, p = 0.008). Follow-up at 3 months revealed no adverse events in this woman, who was left untreated. Median Dose-Length-Product was 117 mGy.cm for CTPA and 675 mGy.cm for CTPA + CTV. CONCLUSION: Performing CTV in women suspected of postpartum PE doubles the detection of venous thromboembolism, at the cost of increased radiation exposure. CLINICAL RELEVANCE STATEMENT: CTV can help in the decision-making process concerning curative anticoagulation in women with suspected postpartum PE, particularly those whose CTPA results are indeterminate or whose PE is limited to the subsegmental level. KEY POINTS: Postpartum women are at risk of pulmonary embolism, and CT pulmonary angiography can give equivocal results. CT venography (CTV) positivity increased the venous thromboembolism detection rate from 5.7 to 11.4%. CTV may help clinical decision-making, especially in women with indeterminate CTPA results or subsegmental emboli.

A Mixed Methods Evaluation of a Quality Improvement Model to Optimize Perinatal and Primary Care in the Community Health Setting.

PURPOSE: Many maternal deaths occur beyond the acute birth encounter. There are opportunities for improving maternal health outcomes through facilitated quality improvement efforts in community settings, particularly in the postpartum period. We used a mixed methods approach to evaluate a collaborative quality improvement (QI) model in 6 Chicago Federally Qualified Health Centers (FQHCs) that implemented workflows optimizing care continuity in the extended postpartum period for high-risk prenatal patients. METHODS: The Quality Improvement Learning Collaborative focused on the implementation of a registry of high-risk prenatal patients to link them to primary care and was implemented in 2021; study data were collected in 2021-2022. We conducted a quantitative evaluation of FQHC-reported aggregate structure, process, and outcomes data at baseline (2020) and monthly (2021). Qualitative analysis of semistructured interviews of participating FQHC staff focused on the experience of participating in the collaborative. RESULTS: At baseline, none of the 6 participating FQHCs had integrated workflows connecting high-risk prenatal patients to primary care; by the end of implementation of the QI intervention, such workflows had been implemented at 19 sites across all 6 FQHCs, and 54 staff were trained in using these workflows. The share of high-risk patients transitioned to primary care within 6 months of delivery significantly increased from 25% at baseline to 72% by the end of implementation. Qualitative analysis of interviews with 11 key informants revealed buy-in, intervention flexibility, and collaboration as facilitators of successful engagement, and staffing and data infrastructure as participation barriers. CONCLUSIONS: Our findings show that a flexible and collaborative QI approach in the FQHC setting can help optimize care delivery. Future evaluations should incorporate the patient experience and patient-level data for comprehensive analysis.

Prevalence and correlates of very rapid repeat pregnancy: Pregnancy Risk Assessment Monitoring System, United States, 2009-2020.

BACKGROUND: Most rapid repeat pregnancies, defined as those occurring within 18 months of a previous birth, are unintended. These pregnancies are associated with later initiation of prenatal care and are more common among people with lower socio-economic status and among racially and ethnically minoritised populations. OBJECTIVES: To assess prevalence and correlate pregnancies occurring in the immediate period after a live birth in the United States, using the Pregnancy Risk Assessment Monitoring System (PRAMS). METHODS: We assessed data from the 2009-2020 PRAMS, a population-based survey of perinatal maternal characteristics of mothers of liveborn infants in US locations. We assessed pregnancies reported during the immediate postpartum period (approximately 2-6 months post-delivery), and term this 'very rapid repeat pregnancy' (VRRP). We assessed the adjusted prevalence of VRRP from 2009 to 2020. From 2016 to 2020, we calculated adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) for maternal characteristics. RESULTS: The adjusted prevalence of VRRP ranged from 0.38% (95% CI: 0.29, 0.48) in 2009 to 0.76% (95% CI: 0.61, 0.91) in 2020. Demographic characteristics associated with VRRP included younger age, lower educational attainment, and being unmarried. Black mothers had a higher prevalence of VRRP compared to white mothers. Mothers who attended a healthcare visit in the 12 months preconception had a lower prevalence of VRRP as did mothers who attended a postpartum check-up, compared to their counterparts without these visits. Among those receiving prenatal care, mothers whose prenatal healthcare provider asked about postpartum contraception birth had a lower prevalence of VRRP, compared to those not asked about postpartum contraception. CONCLUSIONS: VRRP appeared to increase over time in 2009-2020. Mothers who are younger, Black, have lower educational attainment, or who did not attend healthcare visits before or after pregnancy had a higher prevalence of VRRP and may comprise a population who would benefit from additional family planning resources.

Antiretroviral adherence among people living with HIV during the postpartum period: a retrospective cohort study at a PMTCT reference center in Rio de Janeiro before and during the COVID-19 pandemic.

Despite success in achieving viral suppression during pregnancy in people living with HIV (PLWH), postpartum adherence remains a challenge. We aimed to describe rates of adherence at a Prevention of Mother-to-Child HIV Transmission (PMTCT) Center before and during the COVID-19 pandemic. This study was conducted from a cohort of PLWH who received prenatal care and were virally suppressed near delivery. We tracked combined antiretroviral therapy (cART) pickups for 12 months and HIV viral load (VL) from 2 to 12 months after delivery. We defined flexible adherence as a monthly pickup of cART and strict adherence as also having VL < 200 copies/mL and at least one maternal HIV VL between two and twelve months postpartum. Pre-pandemic was defined as delivery from March 2017-February 2019 and pandemic as March 2020-February 2022. During the study, 1119 PLWH were followed, and 965 (86%) were suppressed near delivery. There were 511 pre-pandemic and 290 pandemic participants. Adherence rates were 66/511 (13%) and 38/290 (13%), respectively. During the pandemic, more participants conceived using cART and were undetectable at the start of prenatal care; nevertheless, postpartum adherence was no better than pre-pandemic underscoring the need to improve strategies for adherence specific to this subset of PLWH in the postpartum period.

Efficacy of antiviral therapy for the prevention of mother-to-child transmission of hepatitis B virus and the risk of postpartum hepatitis flare after discontinuation of antiviral therapy.

The use of nucleos(t)ide analogs (NAs) is recommended for mothers with a high viral load of hepatitis B virus (HBV) during the second or third trimester of pregnancy. However, postpartum hepatitis flares can occur in some cases. We examined the efficacy of NA administration for the prevention of mother-to-child transmission of hepatitis B virus, and evaluated the risk of postpartum hepatitis flares in mothers after NA discontinuation. Nine pregnant women with a high viral load (HBV DNA ≥5.3 log IU/mL) received tenofovir disoproxil fumarate (TDF) at approximately 28 weeks of gestation, and TDF was discontinued at 4-10 weeks after delivery. We evaluated the virological and biochemical parameters in mothers after TDF discontinuation. Hepatitis flares in mothers were defined as alanine transaminase level ≥60 U/L. None of the infants developed any congenital anomaly or acquired HBV infection during infancy. Hepatitis flares occurred within 6 months after TDF discontinuation in five of seven cases, whereas two cases were lost to follow-up. Furthermore, three cases required the resumption of NA use. NA administration was highly effective against mother-to-child-transmission of HBV in pregnant women with high HBV DNA levels. However, hepatitis flares were commonly observed after NA discontinuation in the postpartum period. Patients should be followed up carefully after NA discontinuation, and NA resumption should be considered based on a comprehensive assessment of virological and biochemical parameters.

The Risk Factors of Postpartum Urinary Retention for Women by Vaginal Birth: A Systematic Review and Meta-Analysis.

INTRODUCTION AND HYPOTHESIS: Postpartum urinary retention is one of the most common complications in women during the immediate postpartum period. The objective was to systematically assess risk factors for postpartum urinary retention after vaginal delivery. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we retrieved relevant studies from PubMed, Embase, Cochrane Library, Web of Science Core Collection, China National Knowledge Internet, Wangfang Database, and Chinese Biomedical Database for observational studies investigating the risk factors for postpartum urinary retention from inception to 11 November 2022. The Newcastle-Ottawa Scale and Joanna Briggs Institute's tool were used to assess the risk of bias. We conducted a meta-analysis using RevMan 5.3. RESULTS: In total, 3,074 articles were screened and data from 27 studies were used in the meta-analysis. Sixteen risk factors were identified, namely, labor augmentation (OR = 1.72, 95% CI = 1.17-2.51), primiparity (OR = 2.36, 95% CI = 1.64-3.38), manual fundal pressure (OR = 2.84, 95% CI = 1.00-8.11), perineal hematoma (OR = 7.28, 95% CI = 1.62-32.72), vulvar edema (OR = 7.99, 95% CI = 5.50-11.63), the total duration of labor (MD = 90.10, 95% CI = 49.11-131.08), the duration of the first stage of labor (MD = 33.97, 95% CI = 10.28-57.65), the duration of the second stage of labor (MD = 14.92, 95% CI = 11.79-18.05), the duration of the second stage of labor > 60 min (OR = 3.18, 95% CI = 1.32-7.67), mediolateral episiotomy (OR = 3.65, 95% CI = 1.70-7.83), severe perineal tear (OR = 3.21, 95% CI = 1.84-5.61), epidural analgesia (OR = 3.23, 95% CI = 1.50-6.96), forceps delivery (OR = 4.95, 95% CI = 2.88-8.51), vacuum delivery (OR = 2.44, 95% CI = 1.30-4.58), neonatal birth weight > 4,000 g (OR = 3.61, 95% CI = 1.96-6.65), and neonatal birth weight > 3,500 g (OR = 1.89, 95% CI = 1.12-3.19). CONCLUSIONS: Our results demonstrated that labor augmentation, primiparity, manual fundal pressure, perineal hematoma, vulvar edema, the total duration of labor, the duration of the first stage of labor, the duration of the second stage of labor, the duration of the second stage of labor > 60 min, mediolateral episiotomy, severe perineal tear, epidural analgesia, forceps delivery, vacuum delivery, and neonatal birth weight > 4,000 g and > 3,500 g were risk factors for postpartum urinary retention in women with vaginal delivery. The specific ranges of the first and the second stages of labor causing postpartum urinary retention need to be clarified.

Incidence of Urinary Incontinence During the Postpartum Period in Rajavithi Hospital: A Prospective Cohort Study.

INTRODUCTION AND HYPOTHESIS: The objective was to study the incidence of urinary incontinence (UI), associated risk factors and quality of life (QOL) in postpartum women. METHODS: A prospective study was conducted with 406 postpartum women at Rajavithi Hospital and followed up over the phone between June 2020 and September 2021. Inclusion criteria were singleton pregnant women aged 18-45 years, and gestational age ≥ 37 weeks. Baseline characteristics (age, body mass index, birthweight, gestational age, parity, delivery type, smoking, and alcohol and caffeine intake) were recorded. UI was defined as a score ≥ 16.7% using the Urogenital Distress Inventory. Incontinence-related QOL was evaluated using the Incontinence Impact Questionnaire: a score of ≥ 70 indicated poor QOL. Outcomes were assessed during the postpartum period at 2 days, 6 weeks, 3 months, and 6 months. Multivariate logistic regression was used to analyze risk factors for UI. RESULTS: The incidence of self-reported UI at 2 days, 6 weeks, 3 months, and 6 months postpartum were 39%, 3%, 1%, and 0% respectively. Caffeine consumption during pregnancy was only a risk factor for UI (adjusted RR 1.61, 95%CI 1.27-2.05, p < 0.001) after adjusting for age, BMI, birthweight, parity, delivery type, alcohol, smoking, and pelvic floor exercise. Three women with UI had poor QOL, whereas all women without UI reported a good QOL. CONCLUSION: In our study sample, urinary incontinence was found in one-third of women during the early postpartum period, but for most women symptoms improved with the first 6 weeks and all resolved at 6 months. In this study, caffeine consumption during pregnancy was the only risk factor for UI.

Evaluating the Effectiveness of Radiofrequency Therapy and Manual Pelvic Fascial Release in Treating Myofascial Pelvic Pain.

INTRODUCTION AND HYPOTHESIS: Myofascial pelvic pain (MFPP), characterized by sensitive trigger points in the pelvic floor muscles, leads to chronic pain and affects various aspects of life. Despite the availability of different treatment modalities, there is limited comparative research on their effectiveness. This study compares radiofrequency (RF) therapy and myofascial manual therapy (MMT) in treating MFPP. We aimed to evaluate pelvic floor muscle strength changes, clinical symptoms, and patient comfort during treatment. METHODS: The study involved 176 participants, divided equally into RF and MMT groups. We assessed pelvic floor pain using the Visual Analogue Scale (VAS), muscle strength using the Modified Oxford Scale (MOS) and surface electromyography (sEMG), clinical symptom improvement through questionnaires, and patient discomfort during treatment. RESULTS: Both RF and MMT groups significantly reduced pelvic floor and paraurethral muscle pain (VAS scores, p < 0.001). RF treatment significantly decreased vaginal laxity in its group (p < 0.001), with no notable change in the MMT group (p = 0.818). RF therapy also resulted in greater patient comfort than MMT (p < 0.001). Although both treatments improved clinical symptoms, there was no significant difference between the two (p = 0.692). MOS scores and pelvic floor sEMG values showed no significant differences between the groups before and after treatment (p > 0.05). CONCLUSIONS: Both RF and MMT effectively alleviate pelvic floor pain and improve clinical symptoms in MFPP patients. RF therapy, however, offers additional benefits in reducing vaginal laxity and enhancing treatment comfort.

Continence App® Impact on Puerperal Women's Knowledge, Attitude and Practice: Randomized Clinical Trial.

INTRODUCTION AND HYPOTHESIS: Enhancing women's knowledge, attitude, and practice (KAP) concerning urinary incontinence (UI) through diverse educational strategies has been a focal point for professionals in recent years. This study was aimed at assessing the impact of the educational application Continence App® on the KAP of postpartum women experiencing UI. We hypothesized that access to the app would lead to improved KAP among these women. METHODS: Postpartum women who had undergone vaginal birth, aged 18 years or above, literate, admitted in a maternity ward, delivered a full-term or large-for-gestational-age infant, and possessed a smartphone or compatible device for app usage were included. Changes in KAP were evaluated using a survey specifically designed for this purpose. The Mann-Whitney U test was employed to compare KAP scores between control and intervention groups, as well as between baseline and post-intervention assessments. RESULTS: Among the 542 women screened for eligibility, 349 were enrolled in the study, with 138 completing post-intervention assessments. The mean (standard deviation [SD]) age of participants was 25.9 (5.8) years. Post-intervention scores for knowledge and practice demonstrated a decline among non-app users, whereas a significant increase was observed among those in the intervention group. Attitudinal changes remained insignificant. CONCLUSIONS: The findings highlight the effectiveness of an app-based educational intervention in enhancing the knowledge and practice related to UI among postpartum women.

The receipt of health information on neonatal dangers signs during the immediate postpartum period and its determinants in Ethiopia: a multilevel mixed-effects logistic regression analysis of the 2016 Ethiopian demographic health survey report.

BACKGROUND: Identification of neonatal danger signs and immediate access to health care are two global efforts aimed at enhancing newborn and child survival by preventing 75% of neonatal deaths. Despite various small-scale studies on women's awareness of neonatal danger signs in Ethiopia, little is known about the level of receiving health information on those danger signs during the immediate postpartum period at the national level. Hence, this study aimed at assessing the level, and its determinants of the service uptake in Ethiopia. METHODS: The data for this study was taken from the Ethiopian Demographic and Health Survey (EDHS), which took place from January to June 2016 and covered all administrative regions of Ethiopia. A weighted sample of 7,589.8 women was analyzed using STATA version 16. To account for data clustering, a multivariable multilevel mixed-effect logistic regression analysis was employed to determine the effects of each predictor on the outcome variable. Adjusted odds ratio with its corresponding 95% confidence interval was used to declare the statistical significance of the explanatory variables. RESULTS: The receipt of health information on neonatal danger signs during the immediate postpartum period was 10.70% [95% CI:10.01, 11.40]. Variables namely living in Metropolitans [AOR = 2.06; 95%CI: 1.48, 2.88] and Large central [AOR = 1.83; 95%CI: 1.38, 2.42] regions, being in the highest wealth quintile [AOR = 1.87; 95% CI: 1.23, 2.84], being nulliparous [AOR = 0.27; 95% CI: 0.08, 0.87] and primiparous[AOR = 0.61;95% CI: 0.46, 0.79], getting adequate antenatal visits [AOR = 2.42; 95% CI: 1.75, 3.33], institutional delivery [AOR = 5.91; 95% CI: 4.66, 7.53], and receipt of postnatal visits [AOR = 3.52; 95% CI: 2.84, 4.38] were identified as significant determinants of receiving health information on newborn danger signs. CONCLUSION: The findings revealed that unacceptably low uptake of health information on newborn danger signs during the immediate postpartum period in Ethiopia. A concerted effort is needed from all stakeholders in the health sector to enhance the uptake of maternal health services (antenatal care, skilled delivery service, and postnatal care). Healthcare providers should pay special attention to nulliparous and primiparous women during and after delivery, and the government should also focus on women of peripheral regions, who make up a large portion of the low coverage.

Abnormal obstetric shock index and associated factors among immediate postpartum women following vaginal delivery at a tertiary hospital in southwestern Uganda.

BACKGROUND: Early recognition of haemodynamic instability after birth and prompt interventions are necessary to reduce adverse maternal outcomes due to postpartum haemorrhage. Obstetric shock Index (OSI) has been recommended as a simple, accurate, reliable, and low-cost early diagnostic measure that identifies hemodynamically unstable women. OBJECTIVES: We determined the prevalence of abnormal obstetric shock index and associated factors among women in the immediate postpartum period following vaginal delivery at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda. METHODS: We conducted a cross-sectional study at the labour suite and postnatal ward of MRRH from January 2022 to April 2022. We systematically sampled women who had delivered vaginally, and measured their blood pressures and pulse rates at 1 h postpartum. We excluded mothers with hypertensive disorders of pregnancy. Sociodemographic, medical and obstetric data were obtained through interviewer-administered questionnaires. The prevalence of abnormal OSI was the proportion of participants with an OSI ≥ 0.9 (calculated as the pulse rate divided by the systolic BP). Logistic regression analysis was used to determine associations between abnormal OSI and independent variables. RESULTS: We enrolled 427 women with a mean age of 25.66 ± 5.30 years. Of these, 83 (19.44%), 95% CI (15.79-23.52) had an abnormal obstetric shock index. Being referred [aPR 1.94, 95% CI (1.31-2.88), p = 0.001], having had antepartum haemorrhage [aPR 2.63, 95% CI (1.26-5.73), p = 0.010] and having a visually estimated blood loss > 200 mls [aPR 1.59, 95% CI (1.08-2.33), p = 0.018] were significantly associated with abnormal OSI. CONCLUSION: Approximately one in every five women who delivered vaginally at MRRH during the study period had an abnormal OSI. We recommend that clinicians have a high index of suspicion for haemodynamic instability among women in the immediate postpartum period. Mothers who are referred in from other facilities, those that get antepartum haemorrhage and those with estimated blood loss > 200mls should be prioritized for close monitoring. It should be noted that the study was not powered to study the factors associated with AOSI and therefore the analysis for factors associated should be considered exploratory.