The monoamine serotonin (5-hydroxytryptamine; 5-HT) has been described as a homeostatic regulator of lactation. Recently, our laboratory determined that 5-HT is involved in the regulation of calcium and glucose homeostasis during the transition period in rodents. More specifically, we demonstrate that 5-HT is responsible for calcium mobilization from bone and upregulation of hepatic gluconeogenic enzymes and mammary gland glucose transporters. Our objective was to investigate the correlation between circulating 5-HT concentrations and circulating ionized calcium, parathyroid hormone related-protein (PTHrP), and glucose concentrations on d 1 postpartum. We also investigated the correlation between circulating 5-HT and milk fever and ketosis incidence and severity in multiparous Holstein cows at the onset of lactation. Blood samples were collected from 42 multiparous cows on d 1 of lactation and analyzed for 5-HT, calcium, glucose, and PTHrP. Milk fever (determined subjectively for each cow on d 1 postpartum) and ketosis incidence and severity (scale 1 to 4, determined objectively for each cow during the first 10 d postpartum) were recorded for all animals. Serum 5-HT was positively correlated with serum calcium and with plasma PTHrP (r > 0.37). Serum 5-HT was negatively correlated with milk fever incidence and with ketosis severity (most severe ketosis incidence recorded during the first 10 d postpartum; r < -0.33). Serum calcium and plasma glucose concentrations were negatively correlated with milk fever and ketosis severity, respectively (r < -0.39). These data indicate that 5-HT potentially plays a role in the regulation of calcium and glucose homeostasis during the transition period in cattle, which we previously demonstrated in rodents. Increased circulating concentrations of 5-HT might decrease milk fever at the onset of lactation and ketosis severity during the first 10 d postpartum in dairy cows. Understanding this physiological axis could help describe the underlying mechanisms associated with these periparturient metabolic disorders in dairy cows.

OBJECTIVES:

To compare combined sublingual misoprostol plus oxytocin infusion with intravenous carbetocin for prevention of postpartum hemorrhage (PPH) in patients with risk factors during cesarean section (CS).

METHODS:

In this randomized study, 380 patients were randomly allocated to receive either combined 400 μg sublingual misoprostol before surgery plus 20 IU oxytocin after delivery of baby (n = 190) or intravenous 100 μg carbetocin (n = 190). The main outcome measure was requirement of additional pharmacological uterotonic. Secondary outcomes were the difference in preoperative and postoperative hemoglobin, estimated blood loss, incidence of blood transfusion and adverse effects.

RESULTS:

16.3 % of women who received sublingual misoprostol plus oxytocin infusion required additional uterotonic versus 13.7 % of women who received intravenous carbetocin with no significant difference (p = 0.27). No significant difference between treatment groups in preoperative and postoperative hemoglobin level change, estimated blood loss, incidence of blood transfusion was observed. Shivering and fever were significantly higher with misoprostol plus oxytocin (p = <0.001 and <0.001, respectively).

CONCLUSION:

Both sublingual misoprostol plus oxytocin infusion and intravenous carbetocin are similarly effective for the prevention of PPH in patients with risk factors during CS.

To determine maternal and neonatal outcomes in pregnancies complicated by systemic lupus erythematosus (SLE).In a retrospective cohort study using the Nova Scotia Atlee Perinatal Database, 97 pregnancies in women with SLE, with 99 live births, were compared with 211 355 pregnancies in women without SLE and their 214 115 babies. All were delivered in Nova Scotia between 1988 and 2008.In women with SLE, gestational age at birth and mean neonatal birth weight were lower (P < 0.001) than in women without SLE. On bivariate analysis, severe preeclampsia, Caesarean section, newborn resuscitation for > 3 minutes, respiratory distress syndrome, assisted ventilation, bronchopulmonary dysplasia, patent ductus arteriosus, mild to moderate intraventricular hemorrhage, retinopathy of prematurity, and congenital heart block in neonates were significantly more frequent in the women with SLE. Logistic regression analysis identified that having SLE increased the risks of Caesarean section (OR 1.8; 95% CI 1.1 to 2.8, P = 0.005), postpartum hemorrhage (OR 2.4; 95% CI 1.3 to 4.3, P = 0.003), need for blood transfusion (OR 6.9; 95% CI 2.7 to 17, P = 0.001), postpartum fever (OR 3.2; 95% CI 1.7 to 6.1, P = 0.032), small for gestational age babies (OR 1.7; 95% CI 1.005 to 2.9, P = 0.047), and gestational age ≤ 37 weeks (OR 2.1; 95% CI 1.3 to 3.4, P = 0.001). Neonatal death was not shown to be more common in women with SLE (RR 3.05; CI 0.43 to 21.44, P = 0.28).Mothers with SLE have an increased risk of Caesarean section, postpartum hemorrhage, and blood transfusion. They are more likely to deliver premature babies, smaller babies, and babies with congenital heart block.

OBJECTIVE:

To evaluate the effect of maternal chronic disease on obstetric complications among twin pregnancies.

DESIGN:

Multicenter, retrospective, observational study.

SETTING:

Clinical centers (19 hospitals).

PATIENT(S):

Twin pregnancies (n = 4,821) delivered ≥23 weeks of gestation and classified by maternal chronic disease (either none or any of the following: asthma, depression, hypertension, diabetes, and heart, thyroid, gastrointestinal or renal disease).

INTERVENTION(S):

None.

MAIN OUTCOME MEASURE(S):

Gestational age at delivery, gestational hypertension, pre-eclampsia, gestational diabetes, placental abruption, placenta previa, hemorrhage, chorioamnionitis, maternal postpartum fever, premature rupture of membranes, labor onset (spontaneous vs. nonspontaneous), route of delivery, and maternal admission to intensive care unit.

RESULT(S):

Women with chronic disease delivered earlier (mean gestational length, 34.1 vs. 34.6 weeks) and were less likely to have term birth (risk ratio 0.80; 95% confidence interval 0.70-0.90). Cesarean delivery after spontaneous labor (risk ratio 1.20; 95% confidence interval 1.05-1.37) was also increased with chronic disease. No statistically significant effects were observed for other complications studied. Women who used assisted reproductive technology were more likely to hemorrhage, independent of chronic disease, but other findings were generally similar to the non-assisted reproductive technology sample.

CONCLUSION(S):

Chronic disease was associated with additional risk of earlier delivery and cesarean section after spontaneous labor in a nationwide sample of US twin pregnancies.

Background:

Impetigo herpetiformis (IH) is a rare pustular dermatosis that typically occurs in pregnant women with unknown etiology. Case Report: We report an 18-year-old primigravida who presented with IH at nearly 30 weeks' gestation and was the first patient reported in mainland China. The patient's condition deteriorated rapidly in spite of treatment with corticosteroids and antibiotics, so we decided to terminate the pregnancy by induction of labor. After vaginal delivery she developed fever and her skin lesions did not disappear naturally. Fortunately her symptoms were resolved with the treatment of antibiotics and acitretin, and at day 60 postpartum her skin lesions had completely disappeared.

Conclusion:

Although IH is associated with high mortality and morbidity in both fetus and mother, a better prognosis could be achieved with an immediate diagnosis and proper treatment. The etiology of IH needs to be further explored and the process of diagnosis and therapy should be standardized.

Deep Vein Thrombosis (DVT) is an important cause of morbidity and is the first cause of maternal death after delivery in Western Nations. The risk of venous thromboembolism is present throughout the pregnancy and is maximal during postpartum, especially after twin delivery. Many of the signs and symptoms of DVT overlap those of a normal pregnancy causing difficulty for diagnosis.We report the case of a 33 year-old woman transferred to our Department one week after caesarean section for twin delivery. She presented with severe abdominal pain, fever, abdominal distension and shortness of breath. She had no personal or family history of thromboembolism. Computerized Tomography Scan revealed right ovarian vein thrombosis, left renal vein thrombosis extending up to the Inferior Vena Cava and pulmonary embolism with bilateral pleural effusion. Caval filter was positioned and anticoagulation therapy associated with antibiotics was instituted. Pancreatitis showed up two days after and was promptly treated. Three months after discharge the caval filter was removed and oral anticoagulation was stopped. During a 12-months follow-up, she remained stable and symptom free.Ovarian vein thrombosis is rare but recognition of signs and symptoms is fundamental to start adequate therapy and avoid potential serious sequelae. The risk for maternal postpartum ovarian vein thrombosis is increased by caesarean section delivery of twins. Such patients should be closely monitored. We illustrated how an underestimated condition can lead to massive complications.

Group A streptococcus (GAS)-induced toxic shock syndrome (TSS) in pregnancy is rare, but its clinical course is fulminant. The mortality rates of mother and fetus are reported to be 58 and 66%, respectively. We report a case of GAS-TSS after cesarean section. A 38-year-old pregnant woman of 38 weeks gestation was admitted to our hospital because of vomiting, fever of 39 degrees C, and continuous abdominal pain with scanty genital bleeding. She had complained of sore throat several days before. One hour after admission, external fetal monitoring revealed periodic pulse deceleration to 90 x beats min(-1). The emergent cesarean section was performed under general anesthesia. Approximately 8 hours after the cesarean section, she developed coma, shock and respiratory insufficiency requiring intubation. Streptococcus pyogens were isolated from her blood sample and the patient met criteria for GAS-TSS. She was treated with antibiotics (penicillin and clindamycin), antithrombin III, recomodulin, catecholamins, and continuous hemodialysis with filtration of toxins. Although the patient recovered and was discharged on 63rd day, the infant died on postpartum day 4. Early recognition and intensive treatment for GAS is recommended in a late stage pregnancy with an episode of sore throat, vomiting, high fever, strong labor pain, and DIC signs.

To compare immediate with delayed (4 hours) oxytocin infusion after amniotomy on vaginal delivery within 12 hours and patient satisfaction with the birth process.Parous women with favorable cervixes after amniotomy for labor induction were randomized to immediate titrated oxytocin or placebo intravenous infusion in a double-blind noninferiority trial. After 4 hours, study infusions were stopped, the women were assessed, and open-label oxytocin was started if required. Maternal satisfaction with the birth process was assessed with a 10-point visual numerical rating scale (lower score, greater satisfaction).Vaginal delivery rates at 12 hours were 91 of 96 (94.8%) compared with 91 of 94 (96.8%) (relative risk 0.98, 95% confidence interval [CI] 0.92-1.04, P=.72), and maternal satisfaction on a visual numerical rating scale (median [interquartile range]) was 3 [3-4] compared with 3 [3-5], P=.36 for immediate compared with delayed arm, respectively). Cesarean delivery, maternal fever, postpartum hemorrhage, uterine hyperactivity, and adverse neonatal outcome rates were similar between arms. The immediate oxytocin arm had a shorter amniotomy-to-delivery interval of 5.3±3.1 compared with 6.9±2.9 hours (P<.001) and lower epidural analgesia rate of 2.9% compared with 9.9% (relative risk 0.3, 95% CI 0.1-1.0, P=.046), but fetal heart rate abnormalities on cardiotocogram were higher, 28.6% compared with 16.8% (relative risk 1.7 95% CI 1.0-2.9, P=.048). In the delayed arm, oxytocin infusion was avoided by 35.6%.Immediate or delayed oxytocin infusions are reasonable options after amniotomy for labor induction in parous women with favorable cervixes. The choice should take into account local resources and the woman's wish.ISRCTN Register, http://isrctn.org, ISRCTN51476259.I.

Clostridium sordellii is gram positive anaerobic spore forming rod and it has been demonstrated to cause gas gangrene, refractory shock, leukemoid reaction, and pleuroperitoneal effusion due to capillary leak. We report here a case of postpartum female who presented with leukemoid reaction, ascites, pleural effusion, and shock without fever 7 days after normal vaginal home delivery.