Primary versus Nonprimary Cytomegalovirus Infection during Pregnancy,

Galia Rahav,*1 Comments to Author Rinat Gabbay,* Asher Ornoy,*† Svetlana Shechtman,† Judith Arnon,† and Orna Diav-Citrin†
*Hadassah Medical Center–Hebrew University School of Medicine, Jerusalem, Israel; and †Israel Ministry of Health, Jerusalem, Israel

Volume 13, Number 11–November 2007

Suggested citation for this article

Abstract
We examined prospectively the outcome of primary and nonprimary maternal cytomegalovirus (CMV) infection during pregnancy among 88 and 120 women, respectively. The risk for vertical transmission was 1.83× higher for primary infection than for nonprimary infection. Nonetheless, congenital CMV disease was diagnosed in both infection groups at similar rates.

Cytomegalovirus (CMV) infection is the most frequent congenital infection and a common cause of deafness and intellectual impairment, affecting 0.5%–2.5% of all live births (1–3). Intrauterine infection occurs in 40% of primary maternal infections, with delivery of 10% to 15% symptomatic newborns and late neurologic sequelae in 10% of those asymptomatic at birth (1).

Although preexisting maternal immunity reduces maternal-fetal transmission, the severity of congenital CMV disease is similar following primary or nonprimary infection (4–7). Yet, several reports found increased vertical transmission after nonprimary CMV infection (4–9). Therefore, our objective was to examine the outcome of primary and nonprimary maternal CMV infections during pregnancy.


The Study

Institutional Ethics Committee approval was obtained. Women with positive CMV immunoglobulin (Ig) M (n = 208), referred for risk for CMV infection between January 1998 and December 2001, were enrolled in this prospective cohort observational study. Clinical and pregnancy-related information was obtained. Serum CMV IgG and IgM were measured by enzyme immunoassay and CMV-IgM immunofluorescence assay (10). IgG avidities .

PRIMARY INFECTION was defined as the occurrence of anti–CMV IgG seroconversion during pregnancy (1). Women who were seropositive for anti–CMV IgM and anti–CMV IgG when first evaluated during pregnancy and with IgG avidity >35% were considered to have NONPRIMARY INFECTION (12). The latter were divided into those with preconception evidence of anti–CMV IgG and negative anti–CMV IgM (group 1) and those without prior tests for CMV (group 2). Vertical transmission was declared if the amniotic fluid contained CMV virus or DNA, if pathologic features of CMV disease existed in the aborted fetus, or if neonatal IgM or urine cultures were positive for CMV.

Analysis of variance and the Kruskal-Wallis or Mann-Whitney tests were used. Frequencies were compared by χ2 or Fisher exact tests. Relative risk was calculated with Epi Info 2000 software (available from www.cdc.gov/epiinfo).

Of the 208 enrolled women, 88 (42.3%) had primary CMV infection; 120 (57.7%) had nonprimary CMV infection, 36 (17.3%) from group 1 and 84 (40.4%) from group 2. The mothers' ages were similar in both groups. The median gestational age upon referral was 15 weeks (9.5–19.0 weeks), and the median number of pregnancies was 3 (range 1–10). CMV serologic testing was part of the routine gynecologic examination in 127 (61.0%) of the women: 35 (39.8%) after primary infection and 92 (76.6%) in the nonprimary infection group (p<0.001). p =" 0.002)." p =" 0.004)." n =" 12)" n =" 30)," n =" 6)," n =" 2)" n =" 13)." p =" 0.017)." p =" 0.019)" p =" 0.26)." n ="">Furthermore, of the 11 cases of congenital CMV disease, 7 were associated with nonprimary maternal infection.

The high rate of vertical transmission in the nonprimary infection group attests to the numerous amniocenteses performed in Israel to exclude fetal infection. The procedure is considered safe because neonatal loss rates in those undergoing it and not undergoing it are identical (14), and the risks of undergoing the procedure do not outweigh the risks for congenital CMV infection. In the nonprimary group, 67 (55.8%) had amniocentesis, but in the primary infection group, only 33 (37.5%) underwent the procedure, which reflects the increased early ETOP rate with primary infection.

Traditionally, vertical transmission after nonprimary infection was established by isolating CMV from neonatal saliva or urine, or the presence of neonatal IgM (4–8). We, however, determined transmission also from CMV in the amniotic fluid, and the observed difference between amniotic CMV and neonatal CMV disease suggests fetal virus elimination between amniocentesis and birth, probably by preexisting maternal CMV-specific antibodies. The high transmission rate could have resulted also from reinfection by CMV strains different from the primary strain (6), further enhanced by increased virulence of present-day strains.

The high proportion (>40%) of religiously observant women accounts for the reluctance of some to terminate pregnancy without ultrasonographic and amniocentesis evidence of fetal infection and also for the increased early ETOP (permitted by Jewish law only before the second trimester). We are aware that data were obtained for only 169/199 (84.9%) of fetuses or newborns and that only 31/51 (60.8%) of the aborted fetuses were available for examination, but omissions were random. Possible referral selection bias and the low number of affected women discourage definitive conclusions
nevertheless BOTH PRIMARY AND NONPRIMARY CMV INFECTION DURING PREGNANCY ARE CLEARLY IMPORTANT CAUSES OF CONGENITAL DISEASE



Dr Rahav is the director of the Infectious Diseases Unit, Sheba Medical Center, Tel-Hashomer, Israel. Her research interests include mycobacterial infections, bacterial strain typing, HIV-1 reverse transcriptase, and congenital CMV infection.

References

1. Stagno S, Pass RF, Cloud G, Britt WJ, Henderson RE, Walton PD, et al. Primary cytomegalovirus infection in pregnancy. Incidence, transmission to fetus, and clinical outcome. JAMA. 1986;256:1904–8.
2. Fowler KB, Stagno S, Pass RF, Britt WJ, Boll TJ, Alford CA. The outcome of congenital cytomegalovirus infection in relation to maternal antibody status. N Engl J Med. 1992;326:663–7.
3. Revello MG, Gerna G. Diagnosis and management of human cytomegalovirus infection in the mother, fetus, and newborn infant. Clin Microbiol Rev. 2002;15:680–715.
4. Boppana SB, Fowler KB, Britt WJ, Stagno S, Pass RF. Symptomatic congenital cytomegalovirus infection in infants born to mothers with preexisting immunity to cytomegalovirus. Pediatrics. 1999;104:55–60.
5. Ahlfors K, Ivarsson SA, Harris S. Report on a long-term study of maternal and congenital cytomegalovirus infection in Sweden. Review of prospective studies available in the literature. Scand J Infect Dis. 1999;31:443–57.
6. Boppana SB, Rivera LB, Fowler KB, Mach M, Britt WJ. Intrauterine transmission of cytomegalovirus to infants of women with preconceptional immunity. N Engl J Med. 2001;344:1366–71.
7. Ahlfors K, Harris S. Secondary maternal cytomegalovirus infection—a significant cause of congenital disease. Pediatrics. 2001;107:1227–8.
8. Daiminger A, Bäder U, Enders G. Pre- and periconceptional primary cytomegalovirus infection: risk of vertical transmission and congenital disease. BJOG. 2005;112:166–72.
9. Ross SA, Fowler KB, Ashrith G, Stagno S, Britt WJ, Pass RF, et al. Hearing loss in children with congenital cytomegalovirus infection born to mothers with preexisting immunity. J Pediatr. 2006;148:332–6.
10. Lazzarotto T, Varani S, Gabrielli L, Spezzacatena P, Landini MP. New advances in the diagnosis of congenital cytomegalovirus infection. Intervirology. 1999;42:390–7.
11. Liesnard C, Donner C, Brancart F, Gosselin F, Delforge ML, Rodesch F. Prenatal diagnosis of congenital cytomegalovirus infection: prospective study of 237 pregnancies at risk. Obstet Gynecol. 2000;95:881–8.
12. Nigro G, Mazzocco M, Anceschi MM, La Torre R, Antonelli G, Cosmi EV. Prenatal diagnosis of fetal cytomegalovirus infection following primary or recurrent maternal infection. Obstet Gynecol. 1999;94:909–14.
13. Fowler KB, Stagno S, Pass RF. Maternal immunity and prevention of congenital cytomegalovirus infection. JAMA. 2003;289:1008–11.
14. Eddleman KA, Malone FD, Sullivan L, Dukes K, Berkowitz RL, Kharbutli Y, et al. Pregnancy loss rates after midtrimester amniocentesis. Obstet Gynecol. 2006;108:1067–72.

Tables

Table 1. Outcome of pregnancies by type of CMV infection
Table 2. Characteristics of aborted fetuses and neonates with congenital CMV disease

Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, U.S.A
Tel: (404) 639-3311 / Public Inquiries: (404) 639-3534 / (800) 311-3435

LEARN ABOUT CYTOMEGALOVIRUS

Learn about Cytomegalovirus

A pregnant womanWhile most children with cytomegalovirus (CMV) don't get sick, the disease can lead to birth defects or other serious problems―even death. If you're pregnant or planning a pregnancy, the best way to protect your unborn child from CMV is to protect yourself.



Pregnant or planning a pregnancy?

Here are a few simple steps you can take that may reduce your chance of getting CMV and potentially passing it along to your unborn baby:

* Wash your hands often with soap and water for 15–20 seconds, especially after changing diapers or touching saliva or nasal secretions from a young child.
* Reduce contact with saliva and nasal secretions from young children by 1) using soap and water or a disinfectant to clean hard surfaces that have been contaminated by secretions, 2) not sharing food, drinks, or eating utensils with young children, and 3) being careful to limit kissing them on the lips.
* If you work in a day care center, limit close contact with children younger than 2 ½ years of age, especially if you've never been infected with CMV or don't know if you've been infected.

Cytomegalovirus (CMV) is a common virus related to the viruses that cause chickenpox and mononucleosis. CMV can infect almost anyone, and once infected, a person has the virus in their body for life. Since there are different strains of the virus, people can be infected more than once.

Most people with CMV never show symptoms, or they experience only mild illness for a short time after they're infected. However, CMV can cause serious health problems in some unborn babies and people with weak immune systems.

CMV and Pregnancy

The risk of getting CMV through casual contact is very small. The virus is generally passed from infected people to others through direct contact with body fluids, such as urine, saliva, breast milk, or blood.

If you become infected with CMV while you're pregnant, there's as much as a 1 in 3 chance you could pass the virus to your unborn baby. If you are infected with CMV before you become pregnant, that risk is reduced to about 1 in 100. If you're pregnant or planning a pregnancy and have concerns about CMV, talk with your healthcare provider.

Practicing good hygiene can reduce your chance of infection while pregnant. Remember to wash your hands with soap and water after changing diapers and coming into contact with children's body fluids. Avoid kissing young children on the face or lips. And don't share food, drinks, or eating utensils with young children.
Signs and Symptoms

While most children and adults infected with CMV don't show any symptoms, some develop a mild illness that can include fever, sore throat, fatigue, or swollen glands. Because these symptoms are like those of other illnesses, you might not realize you or your child has CMV.

About 1 in 150 children is born with CMV. When newborns have CMV, the condition is known as congenital CMV. Some babies with congenital CMV will show symptoms that can be temporary or permanent. Temporary symptoms can include the following:

* Small body size
* Problems with the liver, spleen, and/or lungs
* Jaundice (yellow skin and eyes)
* Purple-looking skin
* Seizures



Permanent problems from congenital CMV can include the following:

* Loss of hearing and/or vision
* Mental disability
* Small head
* Lack of coordination
* Seizures

In some cases, congenital CMV can even lead to death.

Treatment

A drug called ganciclovir is used to treat CMV primarily in adults who also have a weak immune system or a life-threatening illness. Ganciclovir may also prevent hearing loss in children with congenital CMV. However, the drug has been linked to serious side effects in children. If your child has congenital CMV, talk with your healthcare provider about the best course of action.


USA.gov: The U.S. Government's Official Web PortalDepartment of Health and Human Services
Centers for Disease Control and Prevention 1600 Clifton Rd. Atlanta, GA 30333, USA
800-CDC-INFO (800-232-4636) TTY: (888) 232-6348, 24 Hours/Every Day - cdcinfo@cdc.gov

BARTHOLINI CYST

Definition

By Mayo Clinic staff

The Bartholin's glands are located on each side of the vaginal opening. These glands secrete fluid that helps lubricate the vagina. Sometimes the openings of these glands become obstructed causing fluid to back up into the gland, resulting in relatively painless swelling called a Bartholin cyst. At times, this fluid may become infected, creating a small area of pus surrounded by inflamed tissue (abscess).

A Bartholin cyst or abscess is uncommon. Treatment of Bartholin cyst depends on the size of the cyst, the pain and whether it's infected. Sometimes, home treatment is all you need. In other cases, surgical drainage of the Bartholin cyst is necessary. If an infection occurs, antibiotics may be necessary to treat the Bartholin cyst.

Symptoms

If the cyst remains small and no infection occurs, you may not notice it. If it grows, you might feel the presence of a lump or mass near your vaginal opening. Although a cyst is usually painless, it can be tender.

If the cyst becomes infected — a full-blown infection can occur in a matter of days — you may experience the following signs and symptoms:

A tender or painful lump near the vaginal opening
Discomfort while walking or sitting
Pain during intercourse
Fever
A cyst or abscess typically occurs on only one side of the vaginal opening (unilaterally).

Causes

Experts believe that the cause of a Bartholin cyst is a backup of fluid. Fluid may accumulate when the opening of the gland (duct) becomes obstructed, perhaps by the growth of a flap of skin.

A cyst can become infected, forming an abscess. A number of bacteria may cause the infection, including common bacteria, such as Escherichia coli (E. coli), as well as bacteria that cause sexually transmitted diseases, such as gonorrhea and chlamydia.


When to seek medical advise

Call your doctor if you have a painful lump near the opening of your vagina and it doesn't improve after two or three days of self-care treatment. If the pain is severe, make an appointment with your doctor right away.

If you find a lump near your vaginal opening and you're older than 40, call your doctor promptly. Although rare, such a lump may be a sign of a more serious problem, such as cancer.

Test and Diagnosis

A history of your signs and symptoms and a pelvic examination is usually sufficient to make a diagnosis. Your doctor may take a swab of your cervix to test for an accompanying sexually transmitted infection, which may need additional treatment with antibiotics.

If you're postmenopausal or older than 40, your doctor may perform a biopsy of the mass to rule out a possibility of cancer. If cancer is a concern, your doctor may refer you to an obstetrician-gynecologist who specializes in cancers of the female reproductive system.

Complications

It's possible that a Bartholin cyst or abscess may recur, but this is not usually the case. When treated properly, even in the case of recurrent cysts or abscesses, the swelling, pain and infection usually go away.


Treatments and Drugs

Treatment of a Bartholin cyst depends on the size of the cyst, the amount of discomfort it causes and whether it's infected, resulting in an abscess. Here are some of the treatment options your doctor may recommend:

Sitz baths. Sometimes, soaking in a tub filled with a few inches of warm water (sitz bath) several times a day for three or four days helps a small, uncomplicated cyst to rupture and drain on its own.
Surgical drainage. A cyst that's infected or very large generally requires drainage by a doctor. Drainage of a cyst can be done in your doctor's office under local anesthesia, but in some cases, you and your doctor may opt for general sedation, if that makes you more comfortable. To do the drainage procedure, your doctor makes a small incision in the cyst to allow it to drain. Then he or she places a small rubber tube (catheter) in the incision. The catheter stays in place for four to six weeks to keep the opening from closing up and to allow complete drainage. After that, the catheter is removed and the incision heals completely.
Antibiotics. If the cyst is infected, or if testing reveals a sexually transmitted disease, your doctor may prescribe antibiotics to ensure that the bacteria causing the infection are destroyed. But if the abscess is drained properly, you may not need antibiotics.
Marsupialization. If cysts recur, your doctor may perform a technique called marsupialization. This method is usually effective in preventing recurrences. It's similar to the surgical drainage procedure, only your doctor places a few stitches on either side of the incision to create a permanent opening, less than one-quarter inch (about 5 millimeters) long. Your doctor may insert a catheter to promote draining for a few days to prevent recurrence. This procedure can be done in your doctor's office but, depending on the complexity of the cyst, may be done in an operating room in the hospital under general anesthesia. Since marsupialization isn't recommended when an active infection is present, your doctor will likely want to drain the abscess first and get rid of the infection, then perform the marsupialization.
If you have persistent recurrences and none of these procedures is successful, your doctor may recommend removal of the Bartholin's gland, but this is rarely necessary. Surgical removal is usually done in a hospital under general anesthesia.

Some doctors are using laser therapy to treat Bartholin cyst but this type of treatment is still in the experimental phase.

Preventions

There's no real way to prevent a Bartholin cyst. However, practicing safe sex — in particular, using a condom — and maintaining good personal hygiene may help to prevent infection of a cyst and the formation of an abscess. If you detect a cyst, treating it right away by soaking in warm water (sitz bath) may help prevent abscess formation, as well.

Lifestyle and home remedies

Daily soaking in warm water, several times a day, may be enough to clear away a Bartholin cyst or abscess.

After surgical procedures to treat a cyst, soaking in warm water (sitz bath) is particularly important. Sitz baths help to keep the area clean, ease discomfort and promote effective drainage of the cyst. Pain relievers also may be helpful. If you have a catheter in place, you may resume your normal activities, including sex, depending on your level of comfort.
Jan. 19, 2008

© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.

OVARIUM CYST

The ovaries are two small organs, one on each side of a woman's uterus. It is normal for a small cyst (a fluid-filled sac or pouch) to develop on the ovaries. In most cases, these cysts are harmless and go away on their own. In other cases, cysts may cause problems and may need treatment. This pamphlet will explain:

* Types of cysts
* Symptoms of ovarian cysts
* How ovarian cysts are treated


Although most cysts are harmless and go away on their own, your doctor will want to keep track of any cyst to be be sure that it does not grow and cause problems.

Your Monthly Cycle

One of a woman's ovaries produces an egg every month during her menstrual cycle. An egg, encased in a sac called a follicle, grows inside the ovary. On about day 5 of the menstrual cycle, the hormone estrogen signals the endometrium to grow and thicken to prepare for a possible pregnancy. About day 14, the egg is released from the ovary. This is called ovulation.

Around the time of ovulation, a woman can get pregnant. The egg moves into one of the two fallopian tubes connected to the uterus where it can be fertilized by a man's sperm. After ovulation, the empty follicle becomes the corpus luteum, which remains until the next period. The corpus luteum makes hormones that prepare the endometrium for the arrival of the egg.

Types of Ovarian Cysts

Ovarian cysts are quite common in women during their childbearing years. A woman can develop one cyst or many cysts. Ovarian cysts can vary in size.

There are many different types of ovarian cysts. Most cysts are benign (not cancerous). A few cysts may turn out to be malignant (cancerous). For this reason, all cysts should be checked by your doctor.

Functional Cysts

The most common type of ovarian cyst is called a functional cyst. It develops from tissue that changes in the normal process of ovulation. There are two types of functional cysts—follicle and corpus luteum. Both of these cysts usually have no symptoms or minor ones when they occur. They disappear within 6–8 weeks.

Dermoid Cysts

Dermoid cysts are made up of different kinds of tissue from other parts of the body, such as skin, hair, fat, and teeth. They may be found on both ovaries. Dermoid cysts often are small and may not cause symptoms unless they become large.

Cystadenomas

Cystadenomas are cysts that develop from cells on the outer surface of the ovary. They usually are benign, but they can grow very large and cause pain.

Warnings of Cancer of the Ovary

* Enlargement or swelling of the abdomen
* Nausea or heartburn that does not go away
* Loss of appetite
* Pelvic pain
* Constipation
* Bloating
* Urinary frequency

See your doctor if you have any of these warning signs
.
Endometriomas

Endometriomas are cysts that form when endometrial tissue grows in the ovaries. This tissue then responds to monthly changes in hormones. The tissue bleeds monthly, which may cause it to form a cyst that slowly grows on the ovary. An endometrioma also is known as a "chocolate cyst" because it is filled with dark, reddish-brown blood.

An endometrioma often is linked to a condition known as endometriosis. It can be painful, especially during a woman's menstrual period or during sexual intercourse.

Symptoms

Most ovarian cysts are small, do not cause symptoms, and go away on their own. Some may cause symptoms because of twisting, bleeding, and rupture. They may cause a dull or sharp ache in the abdomen and pain during sexual intercourse.

Some cysts may be cancerous. Although very rare in young women, the risk of ovarian cancer increases with age. Ovarian cancer often has no symptoms in its early stages, so you should be aware of its warning signs (see box above).

Diagnosis

An ovarian cyst often is found during a routine pelvic exam. When your doctor detects an enlarged ovary, he or she may do other tests. Some of these tests provide further information that is helpful in planning treatment.

* Ultrasound: A procedure that uses sound waves to create pictures of the internal organs that can be viewed on a screen.
* Laparoscopy: A surgical procedure that allows a doctor to look directly inside the body. The lap-aroscope—a thin light-transmitting device—is inserted into the abdomen to view the pelvic organs. Laparoscopy also can be used to treat your cyst.
* Blood tests: Tests to measure substances in the blood and help confirm the diagnosis.

Treatment

If your cyst is not causing any symptoms, your doctor may simply monitor it for 1–2 months. Most functional cysts go away on their own after one or two menstrual cycles.

If your cyst is large or causing symptoms, your doctor may suggest surgery. The extent and type of surgery that is needed will depend on several factors:

* Size and type of cyst
* Your age
* Your symptoms
* Your desire to have children

Sometimes, a cyst can be removed without having to remove the ovary. This is called cystectomy. In other cases, one or both of the ovaries may have to be removed. Your doctor may not know which procedure is needed until the surgery begins.

Finally...

Ovarian cysts are common in women during their childbearing years. Although most cysts are harmless and go away on their own, your doctor will want to keep track of any cyst to be sure that it does not grow and cause problems.

If you have ovarian cysts, you probably have some concerns. Share your concerns with your doctor. You can work together to reduce your risk of further problems.

Glossary

Corpus Luteum: The remains of the egg follicle after ovulation.

Cystectomy: Surgical removal of a cyst.

Endometriosis: A condition in which tissue similar to that normally lining the uterus is found outside of the uterus, usually in the ovaries, fallopian tubes, and other pelvic structures.

Endometrium: The lining of the uterus.

Fallopian Tubes: Tubes through which an egg travels from the ovary to the uterus.

Follicle: The sac-like structure that forms inside an ovary when an egg is produced.

Functional Cyst: A benign cyst that forms on an ovary and usually resolves on its own without treatment.

Hormone: A substance produced by the body to control the functions of various organs.

Pelvic Exam: A manual examination of a woman's reproductive organs.

This Patient Education Pamphlet was developed under the direction of the Committee on Patient Education of the American College of Obstetricians and Gynecologists. Designed as an aid to patients, it sets forth current information and opinions on subjects related to women's health. The average readability level of the series, based on the Fry formula, is grade 6–8. The Suitability Assessment of Materials (SAM) instrument rates the pamphlets as "superior." To ensure the information is current and accurate, the pamphlets are reviewed every 18 months. The information in this pamphlet does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate.

Copyright © November 2005 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

ISSN 1074-8601

Requests for authorization to make photocopies should be directed to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923.

To reorder Patient Education Pamphlets in packs of 50, please call 800-762-2264 or order online at sales.acog.org.

The American College of Obstetricians and Gynecologists
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920

12345/98765

| ACOG Member Login |



Privacy Statement | Important Disclaimer | Copyright Information | Terms of Use | Contact Us
Copyright © 2009 American College of Obstetricians and Gynecologists. Al

Maternal positions and mobility during first stage labour

Annemarie Lawrence1, Lucy Lewis2, G Justus Hofmeyr3, Therese Dowswell4, Cathy Styles5

1Institute of Women's and Children's Health (15), The Townsville Hospital, Douglas, Australia. 2The School of Women's and Infants' Health/The School of Paediatrics and Child Health, The University of Western Australia, Subiaco, Australia. 3Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa. 4Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool , Liverpool, UK. 5Institute of Women's and Children's Health, The Townsville Hospital, Douglas, Australia

Contact address: Annemarie Lawrence, Institute of Women's and Children's Health (15), The Townsville Hospital, 100 Angus Smith Drive, Douglas, Queensland, 4810, Australia. annemarie_lawrence@health.qld.gov.au. annielaw@bigpond.net.au. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: New)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD003934.pub2
This version first published online: 15 April 2009 in Issue 2, 2009. Last assessed as up-to-date: 30 December 2008. (Help document - Dates and Statuses explained).

This record should be cited as: Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub2.

Abstract

Background
It is more common for women in the developed world, and those in low-income countries giving birth in health facilities, to labour in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine contractions and impede progress in labour.

Objectives
The purpose of the review is to assess the effects of encouraging women to assume different upright positions (including walking, sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labour on length of labour, type of delivery and other important outcomes for mothers and babies.

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (November 2008).

Selection criteria
Randomised and quasi-randomised trials comparing women randomised to upright versus recumbent positions in the first stage of labour.

Data collection and analysis
We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. A minimum of two review authors independently assessed each study.

Main results
The review includes 21 studies with a total of 3706 women. Overall, the first stage of labour was approximately one hour shorter for women randomised to upright as opposed to recumbent positions (MD -0.99, 95% CI -1.60 to -0.39). Women randomised to upright positions were less likely to have epidural analgesia (RR 0.83 95% CI 0.72 to 0.96).There were no differences between groups for other outcomes including length of the second stage of labour, mode of delivery, or other outcomes related to the wellbeing of mothers and babies. For women who had epidural analgesia there were no differences between those randomised to upright versus recumbent positions for any of the outcomes examined in the review. Little information on maternal satisfaction was collected, and none of the studies compared different upright or recumbent positions.

Authors' conclusions
There is evidence that walking and upright positions in the first stage of labour reduce the length of labour and do not seem to be associated with increased intervention or negative effects on mothers' and babies' wellbeing. Women should be encouraged to take up whatever position they find most comfortable in the first stage of labour.

Plain language summary

Mothers' position during the first stage of labour
Women in the developed world and in health facilities in low-income countries usually lie in bed during the first stage of labour. Elsewhere, women progress through this first stage while upright, either standing, sitting, kneeling or walking around, although they may choose to lie down as their labour progresses. The attitudes and expectations of healthcare staff, women and their partners have shifted with regard to pain, pain relief and appropriate behaviour during labour and childbirth. A woman semi-reclining or lying down on the side or back during the first stage of labour may be more convenient for staff and can make it easier to monitor progression and check the baby. Fetal monitoring, epidurals for pain relief, and use of intravenous infusions also limit movement. Lying on the back (supine) puts the weight of the pregnant uterus on abdominal blood vessels and contractions may be less strong than when upright. Effective contractions help cervical dilatation and the descent of the baby.

The results of the review suggest that the first stage of labour may be approximately an hour shorter for women who are upright or walk around during the first stage of labour. The women’s body position did not affect the rate of interventions. The review authors identified 21 controlled studies from a number of countries that randomly assigned a total of 3706 women to upright or recumbent positions in the first stage of labour. Nine of the studies included only women who were giving birth to their first baby. The length of the second stage of labour and the numbers of women who achieved spontaneous vaginal deliveries or required assisted deliveries and augmentation were similar between groups, where reported. Use of opioid analgesia was no different, although women randomised to upright positions were less likely to have epidural analgesia. In those studies specifically examining position and mobility for women receiving epidural analgesia (five trials, 1176 women), an upright or recumbent position did not change the length of the first stage of labour (time from epidural insertion to complete cervical dilatation) or rates of spontaneous vaginal, assisted and caesarean delivery. Little information was given on maternal satisfaction or outcomes for babies.


About Wiley InterScience | About Wiley | Privacy | Terms & Conditions
Copyright© 1999-2009 John Wiley & Sons, Inc. All rights reserved.

Genital herpes in pregnancy: information for you

What is genital herpes?
Genital herpes is a common sexually transmitted infection caused by the herpes simplex virus (HSV). There are two types, HSV1 and HSV2. Both types can be found in the genital and anal area (genital herpes). Herpes simplex can also occur around the mouth and nose (cold sores) and fingers and hand (herpetic whitlows). This information is mainly about genital herpes in pregnancy.

In women, genital herpes can occur in the skin in and around the vagina, the vulva (lips around the opening of the vagina), the urethra (tube through which urine empties out of the bladder) and the anus (back passage). In men, it can occur in the skin of the penis, the urethra and in the anal area.

How is genital herpes passed on?
Genital herpes is usually passed from one person to another during sexual contact. Both women and men can get the virus. The herpes simplex virus enters the body through small cracks in the skin or through the soft, moist mucous membranes in the mouth or genital area. Once you have the virus it stays in your body for life.
You may only get one attack (known as an episode) or you may have repeated episodes (known as recurrent episodes). The herpes simplex virus is most likely to be passed on just before, during and straight after an episode. It can be passed on:

through skin to skin contact.
by having vaginal, oral or anal sex or sharing sex toys.
at the time of birth by a mother to her baby.
What are the symptoms of genital herpes?
Some people get genital herpes mildly, some notice no signs or symptoms and for some, the symptoms are very painful. When you have an episode of genital herpes for the first time you may feel unwell and may notice painful sores or watery blisters in your genital area. Many people have an early-warning tingling sensation before an episode occurs.

Symptoms can occur within a short time of coming into contact with the virus or it may be many weeks, months or years before any signs or symptoms appear.

What should I do if I think I have genital herpes?
If you and/or your partner have symptoms which you think are unusual, you should seek further advice. Contact your general practice or a clinic that specialises in sexually transmitted infections (called genitourinary medicine clinics or sexual health clinics). You should have a check-up which may include testing, treatment and advice.

It is possible to have more than one sexually transmitted infection at the same time. You may be offered testing to check for this too.

For information about clinics see Useful organisations.

What could genital herpes mean for my baby?
Most women who have genital herpes have healthy babies by vaginal birth. Genital herpes can be safely treated during pregnancy.

If you get genital herpes before you become pregnant, your immune system will provide protection to your baby when you become pregnant. Recurrent episodes of genital herpes during pregnancy do not affect the baby.

If you get genital herpes for the first time after you become pregnant, this can be more serious.

If you get genital herpes in the first 3 months of pregnancy, there is a small chance of miscarriage.
If you get genital herpes for the first time late in your pregnancy (within 6 weeks of birth), there will not be time for your immune system to provide enough protection to your baby. If you then give birth vaginally, there will be about a 4 in 10 (40%) chance of passing the virus to your baby.
If a baby catches the herpes simplex virus at birth, this is known as neonatal herpes. It can be serious but it is very rare in the UK (1–2 out of every 100,000 newborn babies).

Neonatal herpes can cause infections in the baby’s skin and eyes. It may also cause infection of the brain (herpes meningitis) and other body organs. The baby may become seriously ill or die in the first 7 days after birth. Treatment with drugs designed to treat virus infections may help prevent or reduce damage to the baby.

How can I reduce the risk to my baby?
Tell your midwife at your first antenatal appointment if you and/or your partner have ever had the herpes simplex virus (cold sores, whitlows or genital herpes). If you are not sure whether you have the herpes simplex virus, ask for a check-up.

Your can reduce the risk to your baby in the following ways.

If your partner is having an episode of the herpes simplex virus (cold sores, genital herpes or herpetic whitlows), you should avoid skin-to-skin contact with the affected area. This might include avoiding:
vaginal intercourse
anal intercourse
oral intercourse.
As there is a very small risk that a sexual partner who has genital herpes can pass on the infection even when there are no signs or symptoms, you may consider using condoms throughout your pregnancy, particularly in the last 3 months.
Avoid skin-to-skin contact between your baby and anyone with an active herpes simplex infection, such as a cold sore on the mouth or nose or herpetic whitlow on the hand.
Ensure that you wash your hands after touching any sores.
What treatment will I be offered?
If your doctor or midwife thinks you have got genital herpes for the first time while you are pregnant, you should be referred to a specialist genitourinary medicine clinic. You will be offered appropriate testing, treatment and support.

If you have genital herpes for the first time when you are pregnant, you may be offered antiviral tablets called aciclovir and you may be admitted to hospital if it is very painful or you cannot pass urine.

If you have frequent recurrent episodes of genital herpes during pregnancy, you may be given continuous aciclovir treatment from 36 weeks of pregnancy to birth.

The aim of treatment is to help reduce the length and severity of your symptoms.

Are there any risks in treatment?
Aciclovir has been used for many years and when used in pregnancy it has not been shown to harm the baby. It can be used safely during breastfeeding.

Will I need a caesarean delivery?
Most women with genital herpes will have a normal vaginal birth.

If you were infected with genital herpes before you became pregnant, you will not need a caesarean delivery.
If you develop genital herpes for the first time in the last 6 weeks of pregnancy, you will be offered a planned caesarean delivery.
If you get a recurrent episode of genital herpes at the onset of labour, you will not normally need a caesarean delivery. Your doctor or midwife will discuss this with you to help you decide how you would like your baby to be born.
A glossary of all medical terms is available on the RCOG website:

Useful organisations
Herpes Viruses Association
41 North Road London N7 9DP Helpline: 0845 123 2305
Email: info@herpes.org.uk
Website: www.herpes.org.uk

fpa
50 Featherstone Street London EC1Y 8QU Helpline: 0845 122 8690 Website: www.fpa.org.uk Visit the ‘Find a clinic’ section of the fpa website for details of your nearest sexual health clinic.

Sources and acknowledgements
This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline Management of Genital Herpes in Pregnancy (originally published by the RCOG in 2002 and revised in September 2007). This information will also be reviewed, and updated if necessary, once the guideline has been reviewed. The guideline contains a full list of the sources of evidence we have used. You can find it online

Clinical guidelines are intended to improve care for patients. They are drawn up by teams of medical professionals and consumer representatives who look at the best research evidence available and make recommendations based on this evidence.

This information has been developed by the Patient Information Subgroup of the RCOG Guidelines Committee, with input from the Consumers’ Forum and the authors of the clinical guideline. It has been reviewed before publication by women attending clinics in Burton on Trent, London and Oxford. The final version is the responsibility of the Guidelines Committee of the RCOG.

The RCOG consents to the reproduction of this document providing that full acknowledgement is made.

To have or not to have: The critical importance of reproductive rights to the paradox of population policies in the 21st century

Gill Greer,

International Planned Parenthood Federation, London, UK


Available online 18 June 2009.
Abstract

Reproductive rights continue to be under threat, even some 15 years after the landmark International Conference on Population and Development in Cairo declared the importance of a satisfying and safe sex life, the capability to have children, and the right to decide on the timing, number, and spacing. The right to choose whether and when to have children is at risk both from some who seek to increase birth rates through pronatalist policies and from some who seek a return to “population control” as a response to global climate change, environmental degradation, endemic poverty, global recession, and food shortages. This paper argues the success of the rights-based approach to family planning, reproductive health and health education, and outlines issues and policy responses related to low fertility. This is contrasted with the unmet need for family planning in the poorest countries. It calls for health providers to advocate for reproductive rights, affirming that the freedom of women to control their fertility is the basis for other essential freedoms.

Keywords: Fertility; Policy responses; Sexual and reproductive rights

Article Outline

1. Perspectives on populations
2. Diverse policy approaches
3. A comprehensive rights-based approach to sexual and reproductive health
4. Meeting the unmet need
References

IPPF, 4 Newhams Row, London SE1 3UZ, UK.



International Journal of Gynecology & Obstetrics
Article in Press, Corrected Proof - Note to users



Copyright © 2009 Elsevier B.V. All rights reserved. ScienceDirect® is a registered trademark of Elsevier B.V.

Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics

[Intervention Review]
Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics

Dusanka Zaric1, Nathan Leon Pace2

1Department of Anaesthesiology, University of Copenhagen, Frederiksberg Hospital, Denmark, Frederiksberg, Denmark. 2Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA

Contact address: Dusanka Zaric, Department of Anaesthesiology, University of Copenhagen, Frederiksberg Hospital, Denmark, Nordre Fasanvej 57, Frederiksberg, 2000, Denmark. Dusanka.Zaric@frh.regionh.dk. (Editorial group: Cochrane Anaesthesia Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: New search for studies completed, conclusions not changed)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD003006.pub3
This version first published online: 15 April 2009 in Issue 2, 2009. Last assessed as up-to-date: 14 August 2008. (Help document - Dates and Statuses explained).

This record should be cited as: Zaric D, Pace NL. Transient neurologic symptoms (TNS) following spinal anaesthesia with lidocaine versus other local anaesthetics. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003006. DOI: 10.1002/14651858.CD003006.pub3.

Abstract

Background
Spinal anaesthesia has been in use since 1898. During the last decade there has been an increase in the number of reports implicating lidocaine as a possible cause of temporary and permanent neurologic complications after spinal anaesthesia. Follow up of patients who received uncomplicated spinal anaesthesia revealed that some of them developed pain in the lower extremities after an initial full recovery. This painful condition that occurs in the immediate postoperative period was named 'transient neurologic symptoms' (TNS).

Objectives
To study the frequency of TNS and neurologic complications after spinal anaesthesia with lidocaine compared to other local anaesthetics.

Search strategy
We searched the Cochrane Central Register of Controlled Trials Register (CENTRAL) (The Cochrane Library, Issue 4, 2008); MEDLINE (1966 to August 2008); EMBASE (1980 to week 35, 2008); LILACS (August 2008); and handsearched the reference lists of trials and review articles.

Selection criteria
We included all randomized and quasi-randomized studies comparing the frequency of TNS and neurologic complications after spinal anaesthesia with lidocaine as compared to other local anaesthetics.

Data collection and analysis
Two authors independently evaluated the quality of the relevant studies and extracted the data from the included studies.

Main results
Sixteen trials reporting on 1467 patients, 125 of whom developed TNS, were included in the analysis. The use of lidocaine for spinal anaesthesia increased the risk of developing TNS. There was no evidence that this painful condition was associated with any neurologic pathology; the symptoms disappeared spontaneously by the fifth postoperative day. The relative risk (RR) for developing TNS after spinal anaesthesia with lidocaine as compared to other local anaesthetics (bupivacaine, prilocaine, procaine, levobupivacaine, ropivacaine, and 2-chloroprocaine) was 7.31 (95% confidence interval (CI) 4.16 to 12.86). Mepivacaine was found to give similar results as lidocaine and was therefor omitted from the overall comparison to diminish the heterogeneity.

Authors' conclusions
The risk of developing TNS after spinal anaesthesia with lidocaine was significantly higher than when bupivacaine, prilocaine, or procaine were used. The term 'transient neurological symptoms' implies neurologic pathology. Failing identification of the pathogenesis of TNS, consideration should be given to choosing a neutral descriptive term which does not imply a particular causation. One study about the impact of TNS on patient satisfaction and functional impairment demonstrated that non-TNS patients were more satisfied and had less functional impairment after surgery than TNS patients, but this did not influence their willingness to recommend spinal anaesthesia.

Plain language summary

Temporary pain in the lower extremities following spinal anaesthesia with lidocaine compared to other local anaesthetics
Lidocaine is the drug of choice for inducing spinal anaesthesia in ambulatory surgery because of its rapid onset of action, intense nerve blockade, and short duration of action. The possible side effects of spinal anaesthesia in adults, which develop after recovery, are backache, post-dural puncture headache, and transient neurologic symptoms that are characterized by slight to severe pain in the buttocks and legs. TNS symptoms develop within a few hours and up to 24 hours after anaesthesia. They last, in most cases, up to two days. The present review shows that lidocaine is more likely to cause transient neurologic symptoms than bupivacaine, prilocaine, and procaine. However, these drugs produce prolonged local anaesthetic effects and therefore are not desirable for ambulatory patients. It is possible that the reintroduction of 2-chloroprocaine will solve this lack of a suitable intrathecal local anaesthetic; confirmatory studies are needed.


About Wiley InterScience | About Wiley | Privacy | Terms & Conditions
Copyright© 1999-2009 John Wiley & Sons, Inc. All rights reserved.

Routine prophylactic drugs in normal labour for reducing gastric aspiration and its effects

[Intervention Review]
Routine prophylactic drugs in normal labour for reducing gastric aspiration and its effects

Gillian ML Gyte1, Yana Richens2

1Cochrane Pregnancy and Childbirth Group, Division of Perinatal and Reproductive Medicine, The University of Liverpool, Liverpool, UK. 2Elizabeth Garett Anderson and Obstetric Hospital, University College London Hospital Foundation Trust, London, UK

Contact address: Gillian ML Gyte, Cochrane Pregnancy and Childbirth Group, Division of Perinatal and Reproductive Medicine, The University of Liverpool, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, L8 7SS, UK. ggyte@cochrane.co.uk. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Unchanged)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD005298.pub2
This version first published online: 19 July 2006 in Issue 3, 2006. Last assessed as up-to-date: 30 December 2005. (Help document - Dates and Statuses explained).

This record should be cited as: Gyte GML, Richens Y. Routine prophylactic drugs in normal labour for reducing gastric aspiration and its effects. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD005298. DOI: 10.1002/14651858.CD005298.pub2.

Abstract

Background
Women in normal labour may sometimes go on to have general anaesthesia if labour becomes abnormal, for example if a caesarean section is required. General anaesthesia carries a very small risk of regurgitation and inhalation of stomach contents into the lungs. This can cause inflammation, particularly if the fluid is acidic, and can lead to severe morbidity and very occasionally mortality. Labour hormones increase the risk of gastric aspiration or Mendelsohn's syndrome, though the exact incidence is unknown. The routine administration of acid prophylaxis drugs to all women in normal labour is commonly practiced worldwide, to reduce gastric aspiration by reducing the volume and acidity of stomach contents.

Objectives
To assess the effectiveness of routine prophylaxis drugs for women in normal labour to reduce gastric aspiration and its effects.

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group Trials Register (December 2005), EMBASE (1974 to April 2005) and CINAHL (1982 to April 2005).

Selection criteria
Randomised and quasi-randomised controlled trials of women in normal labour assessing the routine administration of drugs (antacids, H2 receptor antagonists, dopamine antagonists and proton-pump inhibitors) compared with placebo/no treatment, and compared with other drugs for reducing gastric aspiration.

Data collection and analysis
Two review authors independently assessed eligibility, quality, extracted data and performed double-data entry.

Main results
Three trials were included, involving 2465 women, assessing the effects of antacids, H2 receptor antagonists and dopamine antagonists. There were no trials on proton-pump inhibitors. None of the trials were of good quality, and none assessed the incidence of gastric aspiration, Mendelsohn's syndrome or their consequences. All the studies assessed vomiting, and there was limited evidence that vomiting may be reduced by antacids (relative risk (RR) 0.46, 95% confidence interval (CI) 0.27 to 0.77, n = 578, one trial) or by dopamine antagonists given alongside pethidine (RR 0.40, 95% CI 0.23 to 0.68, n = 584, one trial). Comparisons between different drugs showed no significant differences, though the number of participants was small. There was no evidence that H2 receptor antagonists improved outcomes compared with antacids, though only one trial addressed this issue.

Authors' conclusions
There is no good evidence to support the routine administration of acid prophylaxis drugs in normal labour to prevent gastric aspiration and its consequences. Giving such drugs to women once a decision to give general anaesthesia is made, is assessed in another Cochrane review.

Plain language summary

Routine prophylactic drugs in normal labour for reducing gastric aspiration and its effects
No good evidence for drugs, like antacids, in normal labour to reduce the small chance of inhaling some stomach contents if general anaesthesia is required.

Caregivers are often concerned that some woman in normal labour may go on to have a general anaesthetic, either for a caesarean section in labour, or to remove the placenta after birth should it be retained. The concern arises because there is a very small risk that the woman might regurgitate and possibly inhale some of the stomach contents into the lungs (gastric aspiration or Mendelsohn's syndrome) during the general anaesthetic. This can cause severe lung and breathing problems, especially if the stomach contents are acid (low pH), and extremely rarely (one in a million) a woman may die from an anaesthetic problem. Giving drugs to reduce the volume of the stomach contents, or to make them less acid may help to reduce the problem. The review of trials looked to see whether giving such drugs routinely to all women in normal labour was effective. The review identified three trials involving 2465 women but none assessed gastric aspiration, probably because it is a very rare event. Instead the trials all assessed the incidence of vomiting, although there is no proven link between vomiting in labour and gastric aspiration during general anaesthesia. The review found some limited evidence that 1) drugs like antacids may reduce the chance of vomiting in labour, 2) H2 receptor antagonist drugs (like ranitidine) appeared to have a similar impact on outcomes as antacids and 3) dopamine antagonists (like metoclopramide) may reduce the chance on vomiting in labour when given alongside pethidine. Overall, there was no evidence that any of these drugs reduced the incidence of gastric aspiration or Mendelsohn's syndrome.


About Wiley InterScience | About Wiley | Privacy | Terms & Conditions
Copyright© 1999-2009 John Wiley & Sons, Inc. All rights reserved.

Vaccines for women to prevent neonatal tetanus

[Intervention Review]
Vaccines for women to prevent neonatal tetanus

Vittorio Demicheli1, Antonella Barale2, Alessandro Rivetti3

1Health Councillorship - Servizio Regionale di Riferimento per l'Epidemiologia, SSEpi-SeREMI - Cochrane Vaccines Field, Regione Piemonte - Azienda Sanitaria Locale ASL AL, Torino, Italy. 2Servizio Sovrazonale di Epidemiologia , Alessandria, Italy. 3Servizio Regionale di Riferimento per l'Epidemiologia, SSEpi-SeREMI - Cochrane Vaccines Field, Azienda Sanitaria Locale ASL AL, Alessandria, Italy

Contact address: Vittorio Demicheli, Health Councillorship - Servizio Regionale di Riferimento per l'Epidemiologia, SSEpi-SeREMI - Cochrane Vaccines Field, Regione Piemonte - Azienda Sanitaria Locale ASL AL, C.so Regina Margherita 153 bis, Torino, Piemonte, 10122, Italy. Vittorio.DeMicheli@regione.piemonte.it. vittorio.demicheli@regione.piemonte.it. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Unchanged)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD002959.pub2
This version first published online: 19 October 2005 in Issue 4, 2005. Last assessed as up-to-date: 30 June 2007. (Help document - Dates and Statuses explained).

This record should be cited as: Demicheli V, Barale A, Rivetti A. Vaccines for women to prevent neonatal tetanus. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD002959. DOI: 10.1002/14651858.CD002959.pub2.

Abstract

Background
Tetanus is an acute, often fatal, disease caused by an exotoxin produced by Clostridium tetani. It occurs in newborn infants born to mothers who do not have sufficient circulating antibodies to protect the infant passively, by transplacental transfer. Prevention may be possible by the vaccination of pregnant or non-pregnant women, or both, with tetanus toxoid, and the provision of clean delivery services. Tetanus toxoid consists of a formaldehyde-treated toxin which stimulates the production of antitoxin.

Objectives
To assess the effectiveness of tetanus toxoid, administered to women of childbearing age or pregnant women, to prevent cases of, and deaths from, neonatal tetanus.

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2007), The Cochrane Library (2007, Issue 2), MEDLINE (1966 to June 2007), EMBASE (1974 to June 2007). We also used the results from handsearching and consultations with manufacturers and authors.

Selection criteria
Randomised or quasi-randomised trials evaluating the effects of tetanus toxoid in pregnant women or women of childbearing age on numbers of neonatal tetanus cases and deaths.

Data collection and analysis
Three review authors independently assessed trials for inclusion and trial quality, and extracted data.

Main results
Two trials (10,560 infants) were included. One study (1919 infants) assessed the effectiveness of tetanus toxoid in preventing neonatal tetanus deaths. After a single dose, the relative risk (RR) was 0.57 (95% confidence interval (CI) 0.26 to 1.24), and the vaccine effectiveness was 43%. With a two or three dose course, the RR was 0.02 (95% CI 0.00 to 0.30); vaccine effectiveness was 98%. No effect was detected on causes of death other than tetanus. The RR of cases of neonatal tetanus after at least one dose of tetanus toxoid was 0.20 (95% CI 0.10 to 0.40); vaccine effectiveness was 80%. Another study, involving 8641 children, assessed the effectiveness of tetanus-diptheria toxoid in preventing neonatal mortality after one or two doses. The RR was 0.68 (95% CI 0.56 to 0.82); vaccine effectiveness was 32%. In preventing deaths at 4 to 14 days, the RR was 0.38 (95% CI 0.27 to 0.55), and vaccine effectiveness 62% (95% CI 45% to 73%).

Authors' conclusions
Available evidence supports the implementation of immunisation practices on women of childbearing age or pregnant women in communities with similar, or higher, levels of risk of neonatal tetanus, to the two study sites. More information is needed on possible interference of vaccination by malaria chemoprophylaxis on the roles of malnutrition and vitamin A deficiency, and on the quality of tetanus toxoid production and storage.

Plain language summary

Vaccines for women to prevent neonatal tetanus
Vaccinating childbearing women against tetanus rather than influenza or cholera appears to decrease incidence of tetanus in newborn babies but possible adverse effects not assessed.

Neonatal tetanus is an infection causing rigidity, muscle spasm and often death in newborn babies. It is quite common in income-poor countries and comes from insufficient protection being passed from mother to baby in utero together with infection getting into the baby through the umbilical cord stump. The review of two studies (10,560 infants) assessing vaccinating women of childbearing age showed fewer cases of neonatal tetanus when two or three doses were used, but no potential adverse effects were assessed. Administrative and operational aspects also need to be of good quality for vaccination programmes to be effective.


About Wiley InterScience | About Wiley | Privacy | Terms & Conditions
Copyright© 1999-2009 John Wiley & Sons, Inc. All rights reserved.

Treatments for toxoplasmosis in pregnancy

Intervention Review]
Treatments for toxoplasmosis in pregnancy

François Peyron1, Martine Wallon1, Christiane Liou2, Paul Garner3

1Service de Parasitologie, Hôpital de la Croix-Rousse, 69004 Lyon, France. 2Service de Parasitologie, Université Claude Bernard Lyon 1, 69008 Lyon, France. 3International Health Group, Liverpool School of Tropical Medicine, Liverpool, UK

Contact address: François Peyron, Service de Parasitologie, Hôpital de la Croix-Rousse, 103 grande rue de la Croix-Rousse, 69004 Lyon, France. francois.peyron@chu-lyon.fr. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Unchanged)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD001684
This version first published online: 26 July 1999 in Issue 3, 1999. Last assessed as up-to-date: 27 February 2006. (Help document - Dates and Statuses explained).

This record should be cited as: Peyron F, Wallon M, Liou C, Garner P. Treatments for toxoplasmosis in pregnancy. Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD001684. DOI: 10.1002/14651858.CD001684.

Abstract

Background
Toxoplasmosis is a widespread parasitic disease and usually causes no symptoms. However, infection of pregnant women may cause congenital infection, resulting potentially in mental retardation and blindness in the infant.

Objectives
The objective of this review was to assess whether or not treating toxoplasmosis in pregnancy reduces the risk of congenital toxoplasma infection.

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2006).

Selection criteria
Randomised controlled trials of antibiotic treatment versus no treatment of pregnant women with proven or likely acute Toxoplasma infection, with outcomes in the children reported. We also inspected relevant reports of less robust experimental studies in which there were (non randomly allocated) control groups, although it was not planned to include such data in the primary analysis.

Data collection and analysis
Reports of possibly eligible studies were scrutinised by two investigators.

Main results
Out of the 3332 papers identified, none met the inclusion criteria.

Authors' conclusions
Despite the large number of studies performed over the last three decades we still do not know whether antenatal treatment in women with presumed toxoplasmosis reduces the congenital transmission of Toxoplasma gondii. Screening is expensive, so we need to evaluate the effects of treatment, and the impact of screening programmes. In countries where screening or treatment is not routine, these technologies should not be introduced outside the context of a carefully controlled trial.

Plain language summary

Treatments for toxoplasmosis in pregnancy
No randomised trials identified on treatments for toxoplasmosis in pregnancy.

Toxoplasmosis is a widespread parasitic disease that usually causes no symptoms. However, infection in pregnant women may cause infection in the baby, resulting in possible mental disability and blindness. The risk to the baby is related to the gestational age at the time of infection. The greatest risk of transmission to the baby is during the third trimester, but disease is most severe when it is acquired during the first trimester. In some countries pregnant women are screened for toxoplasmosis by testing for antibodies to the parasite. Women who have no antibodies at the beginning of pregnancy but develop antibodies during pregnancy are considered to have active infection and their babies are at increased risk of toxoplasmosis. Antibiotics (spiramycin and sulphonamide) may be prescribed to try to reduce the risk of mother-to-child transmission, and to reduce the severity of infection in the baby; however these drugs have potential adverse toxic effects. Other countries feel the likelihood of success is too low and to risk the potential adverse effects of the drugs on the baby. Screening programmes will have no impact unless the interventions that are given as a result actually reduce congenital infection and improve infant outcomes. Hence this review sought evidence from randomised controlled trials on the effects of treatments on women who showed signs of toxoplasmosis infection during pregnancy. No randomised controlled trials were identified, so there is no sound evidence on which to base screening and treatment programmes; such evidence is needed and trials of adequate size should be undertaken.


About Wiley InterScience | About Wiley | Privacy | Terms & Conditions
Copyright© 1999-2009 John Wiley & Sons, Inc. All rights reserved.

Prenatal education for congenital toxoplasmosis

Intervention Review]
Prenatal education for congenital toxoplasmosis

Simona Di Mario1, Vittorio Basevi1, Carlo Gagliotti2, Daniela Spettoli1, Gianfranco Gori1, Roberto D'Amico3, Nicola Magrini1

1CeVEAS, Centro per la Valutazione della Efficacia della Assistenza Sanitaria, Azienda USL di Modena, Modena, Italy. 2Agenzia sanitaria e sociale regionale dell'Emilia-Romagna, Bologna, Italy. 3Dipartimento di Oncologia ed Ematologia, Università di Modena e Reggio Emilia, Modena, Italy

Contact address: Simona Di Mario, CeVEAS, Centro per la Valutazione della Efficacia della Assistenza Sanitaria, Azienda USL di Modena, V. le L. Muratori 201, Modena, 41100, Italy. s.dimario@ausl.mo.it. (Editorial group: Cochrane Pregnancy and Childbirth Group.)

Cochrane Database of Systematic Reviews, Issue 2, 2009 (Status in this issue: Unchanged)
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DOI: 10.1002/14651858.CD006171.pub2
This version first published online: 21 January 2009 in Issue 1, 2009. Last assessed as up-to-date: 20 December 2007. (Help document - Dates and Statuses explained).

This record should be cited as: Di Mario S, Basevi V, Gagliotti C, Spettoli D, Gori G, D'Amico R, Magrini N. Prenatal education for congenital toxoplasmosis. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006171. DOI: 10.1002/14651858.CD006171.pub2.

Abstract

Background
Congenital toxoplasmosis is considered a rare but potentially severe infection. Prenatal education about congenital toxoplasmosis could be the most efficient and least harmful intervention, yet its effectiveness is uncertain.

Objectives
To assess the effects of prenatal education for preventing congenital toxoplasmosis.

Search strategy
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2007), CENTRAL (The Cochrane Library 2007, Issue 3), MEDLINE (1966 to November 2007), EMBASE (1980 to November 2007), CINAHL (1982 to November 2007), LILACS (1982 to November 2007) IMEMR (1984 to November 2007), and reference lists of relevant papers, reviews and websites.

Selection criteria
Randomized and quasi-randomized controlled trials (RCT) of all types of prenatal education on toxoplasmosis infection during pregnancy.

Data collection and analysis
Three authors independently assessed study quality and extracted data.

Main results
One cluster-randomized controlled trial (432 women) met the inclusion criteria. However, the overall methodological quality was poor. The authors did not report measure of association but only provided P values (P less than 0.05) for all outcomes. The authors concluded that prenatal education can effectively change pregnant women's behavior as it increased pet, personal and food hygiene. There are no randomized trials on the effect of prenatal education on congenital toxoplasmosis rate, or toxoplasmosis seroconversion rate during pregnancy, but three observational studies consistently suggest that prenatal education might have a positive impact on these outcomes.

Authors' conclusions
Even though primary prevention of congenital toxoplasmosis is considered a desirable intervention, given the lack of related risks compared to secondary and tertiary prevention, its effectiveness has not been adequately evaluated. There is very little evidence from RCTs that prenatal education is effective in reducing congenital toxoplasmosis even though evidence from observational studies suggests it is. Given the lack of good evidence supporting prenatal education for congenital toxoplasmosis prevention, further RCTs are needed to confirm any potential benefits and to further quantify the impact of different sets of educational intervention.

Plain language summary

Prenatal education for congenital toxoplasmosis
Toxoplasmosis infection is caused by a parasite, Toxoplasma gondii. Eating raw or insufficiently cooked meat, not washing hands thoroughly after handling raw meat or gardening, or contact with cats' faeces (directly or indirectly through the soil, or possibly contaminated raw vegetables or fruits) can cause infection. Usually it is asymptomatic and self-limited. If pregnant women have not previously been exposed to the parasite and developed antibodies (immunoglobulins) while pregnant, the infection can be transmitted from the mother to the fetus (congenital toxoplasmosis). This is rare but has potentially serious effects of malformation, mental retardation, deafness and blindness of the infected infant, intrauterine death or stillbirth. The probability of infection is greater during the third trimester but the risk of the fetus developing major clinical signs is greater earlier in pregnancy. Primary prevention or population surveillance involves educating the general public, filtering water, improving farm hygiene to reduce animal infection, and offering prenatal education to pregnant women or women of reproductive age so that they can avoid toxoplasmosis through adopting simple behavioral measures. Evidence supporting prenatal education to prevent congenital toxoplasmosis is limited. It does indicate that prenatal education can change pregnant women's behavior to avoid risk factors for toxoplasmosis infection during pregnancy. The one controlled trial identified by the review authors was from Canada and involved 432 women who were randomly assigned to a 10 minute presentation about toxoplasmosis prevention that focused on cat, food and personal hygiene during their first prenatal class, or to their usual prenatal class.

Losses to follow up of the women participating in prenatal classes were high and 285 completed the post test questionnaire in the third term of pregnancy. Only 5% of the intervention women recalled having obtained specific information on toxoplasmosis prevention during prenatal classes.

We did not find any randomized trials providing data on change of congenital toxoplasmosis rate or exposure to toxoplasmosis in the blood (and seroconversion) during pregnancy.


About Wiley InterScience | About Wiley | Privacy | Terms & Conditions
Copyright© 1999-2009 John Wiley & Sons, Inc. All rights reserved.

Exercise and depression: A means of self-mangement By Gabrielle J. Melin, M.D.( Depression blog )

We all know that exercising is important for cardiovascular health, brain health and overall body health. Can we look at exercise and depression the same way?

Yes, exercise definitely can improve your depression and this has been proven in many scientific studies. Exercise leads to the production of endorphins. Endorphins are the feel-good chemical that all human bodies make. Does exercising mean 60 minutes of power aerobics? No.

Exercise can mean moving more, like parking the car farther away or taking the stairs. Exercise can mean stretching, yoga, jump roping. You get the idea, just move! Make sure to do something that you like and change it up every once in a while. You don't want to get bored. Get a partner to move with.

Tell other people about your goals. Sharing your goals has been shown to make you much more likely to succeed. Does everyone love exercise? No, of course not, but there are many things in life we don't like and do anyway.

As we discussed recently, set yourself up for success by setting small, reasonable goals that you are sure to achieve. This will boost your mood, self-esteem and confidence, which are all areas that depression can affect. Exercise is one way to self-manage your depression.

Self-management is a generic term that means self-directed activity such as thinking, taking medications as prescribed, exercising, etc. that helps treat disease. This concept can be applied to depression, diabetes, heart failure, etc. Make sure to discuss with your physician before beginning any exercise program.

In upcoming blogs, we'll address medications and information on research treatment trials for depression, such as transcranial magnetic stimulation (TMS), deep brain stimulation (DBS) and vagal nerve stimulation.

July 16, 2008

© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.

Aerobic exercise: Top 10 reasons to get physical

Aerobic exercise: Top 10 reasons to get physical
Regardless of age, weight or athletic ability, aerobic exercise is good for you. See why — then prepare yourself to get moving!
By Mayo Clinic staff

At least 30 minutes of daily aerobic activity — such as walking, bicycling or swimming — can help you live longer and healthier. See how aerobic exercise affects your heart, lungs and blood flow. Then get motivated to reap the rewards!
How your body responds to aerobic exercise

During aerobic activity, you repeatedly move large muscles in your arms, legs and hips. You'll notice your body's responses quickly.

You'll breathe faster and more deeply. This maximizes the amount of oxygen in your blood. Your heart will beat faster, which increases blood flow to your muscles and back to your lungs. Your small blood vessels (capillaries) will widen to deliver more oxygen to your muscles and carry away waste products, such as carbon dioxide and lactic acid. Your body will even release endorphins, natural painkillers that promote an increased sense of well-being. What aerobic exercise does for your health

Regardless of age, weight or athletic ability, aerobic activity is good for you. As your body adapts to regular aerobic exercise, you'll get stronger and more efficient. Consider 10 ways that aerobic activity can help you feel better and enjoy life to the fullest.

Aerobic activity can help you:

1. Keep excess pounds at bay. Combined with a healthy diet, aerobic exercise helps you lose weight — and keep it off.
2. Increase your stamina. Aerobic exercise may make you tired in the short term. But over the long term, you'll enjoy increased stamina and reduced fatigue.
3. Ward off viral illnesses. Aerobic exercise activates your immune system. This leaves you less susceptible to minor viral illnesses, such as colds and flu.
4. Reduce health risks. Aerobic exercise reduces the risk of many conditions, including obesity, heart disease, high blood pressure, type 2 diabetes, stroke and certain types of cancer. Weight-bearing aerobic exercises, such as walking, reduce the risk of osteoporosis.
5. Manage chronic conditions. Aerobic exercise helps lower high blood pressure and control blood sugar. If you've had a heart attack, aerobic exercise helps prevent subsequent attacks.
6. Strengthen your heart. A stronger heart doesn't need to beat as fast. A stronger heart also pumps blood more efficiently, which improves blood flow to all parts of your body.
7. Keep your arteries clear. Aerobic exercise boosts your high-density lipoprotein (HDL), or "good," cholesterol and lowers your low-density lipoprotein (LDL), or "bad," cholesterol. The potential result? Less buildup of plaques in your arteries.
8. Boost your mood. Aerobic exercise can ease the gloominess of depression, reduce the tension associated with anxiety and promote relaxation.
9. Stay active and independent as you get older. Aerobic exercise keeps your muscles strong, which can help you maintain mobility as you get older. Aerobic exercise also keeps your mind sharp. At least 30 minutes of aerobic exercise three days a week seems to reduce cognitive decline in older adults.
10. Live longer. People who participate in regular aerobic exercise appear to live longer than those who don't exercise regularly.

Start slowly

Aerobic activity is safe for most people, but sometimes it's important to get a doctor's OK first — especially if you have a chronic health condition. When you're ready to begin exercising, start slowly. You might walk five minutes in the morning and five minutes in the evening. The next day, add a few minutes to each walking session. Pick up the pace a bit, too. Soon, you could be walking briskly for at least 30 minutes a day — and reaping all the benefits of regular aerobic activity.

Other options might include cross-country skiing, aerobic dancing, swimming, stair climbing, bicycling, jogging, elliptical training or rowing. If you have a condition that limits your ability to participate in aerobic activities, ask your doctor about alternatives. If you have arthritis, for example, aquatic exercises may give you the benefits of aerobic activity without stressing your joints.
Feb. 14, 2009

© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.

POST PARTUM DEPRESSION, MAYO CLINIC

Definition


The birth of a baby can trigger a jumble of powerful emotions, from excitement and joy to fear and anxiety. But it can also result in something you might not expect — depression.

Many new moms experience the baby blues after childbirth. An estimated 10 percent of new moms experience a more severe form of emotional distress known as postpartum depression. Rarely, an extreme form of postpartum depression known as postpartum psychosis develops after childbirth.

Postpartum depression isn't a character flaw or a weakness. Sometimes postpartum depression is simply part of giving birth. If you have postpartum depression, prompt treatment can help you manage your symptoms — and enjoy your baby.

Symptoms


Signs and symptoms of depression after childbirth vary depending on the type of depression.

Baby blues
Signs and symptoms of the baby blues — which last only a few days or weeks — may include:

* Mood swings
* Anxiety
* Sadness
* Irritability
* Crying
* Decreased concentration
* Trouble sleeping

Postpartum depression
Postpartum depression may appear to be the baby blues at first — but the signs and symptoms are more intense and longer lasting, eventually interfering with your ability to care for your baby and handle other daily tasks. Signs and symptoms of postpartum depression may include:

* Loss of appetite
* Insomnia
* Intense irritability and anger
* Overwhelming fatigue
* Loss of interest in sex
* Lack of joy in life
* Feelings of shame, guilt or inadequacy
* Severe mood swings
* Difficulty bonding with the baby
* Withdrawal from family and friends
* Thoughts of harming yourself or the baby

Postpartum psychosis
With postpartum psychosis — a rare condition that typically develops within the first two weeks after delivery — the signs and symptoms are even more severe. Signs and symptoms of postpartum psychosis may include:

* Confusion and disorientation
* Hallucinations and delusions
* Paranoia
* Attempts to harm yourself or the baby

Causes



There's no single cause for postpartum depression. Physical, emotional and lifestyle factors may all play a role.

* Physical changes. After childbirth, a dramatic drop in estrogen and progesterone may contribute to postpartum depression. The hormones produced by your thyroid gland also may drop sharply — which can leave you feeling tired, sluggish and depressed. Changes in your blood volume, blood pressure, immune system and metabolism can lead to fatigue and mood swings.
* Emotional factors. When you're sleep deprived and overwhelmed, you may have trouble handling even minor problems. You may be anxious about your ability to care for a newborn. You may feel less attractive or struggle with your sense of identity. You may feel that you've lost control over your life. Any of these factors can contribute to postpartum depression.
* Lifestyle influences. Many lifestyle factors can lead to postpartum depression, including a demanding baby or older siblings, difficulty breast-feeding, exhaustion, financial problems, and lack of support from your partner or other loved ones.


Risk factors


Postpartum depression can develop after the birth of any child, not just the first. The risk increases if:

* You have a history of depression, either during pregnancy or at other times
* You had postpartum depression after a previous pregnancy
* You've experienced stressful events during the past year, including illness, job loss or pregnancy complications
* You're experiencing marital conflict
* You have a weak support system
* The pregnancy is unplanned or unwanted

The risk of postpartum psychosis is higher for women who have bipolar disorder.

When to seek medical advice


If you're feeling depressed after your baby's birth, you may be reluctant or embarrassed to admit it. But it's important to tell your doctor. If the signs and symptoms of depression don't fade after a few weeks or if they're so severe that they interfere with your ability to complete everyday tasks, call your doctor. Early intervention can speed your recovery.

If you suspect that you're developing postpartum psychosis, seek medical attention immediately. Don't wait and hope for improvement. Postpartum psychosis may lead to life-threatening thoughts or behaviors. Tests and diagnosis
By Mayo Clinic staff

To distinguish between a short-term case of the baby blues and a more severe form of depression, your doctor may ask you to complete a depression-screening questionnaire. Blood tests can help your doctor determine whether an underactive thyroid is contributing to your signs and symptoms.

Complications

Left untreated, postpartum depression can interfere with mother-child bonding and cause family distress. Children of mothers who have untreated postpartum depression are more likely to have behavioral problems, such as sleeping and eating difficulties, temper tantrums and hyperactivity. Delays in language development are common as well.

Untreated postpartum depression can last up to a year or longer. Sometimes untreated postpartum depression becomes a chronic depressive disorder. Even when treated, postpartum depression increases a woman's risk of future episodes of major depression.

Treatments and drugs

Treatment and recovery time vary, depending on the severity of your depression and your individual needs.

Baby blues
The baby blues usually fade on their own within a few days to weeks. In the meantime, get as much rest as you can. Accept help from family and friends. Connect with other new moms. Avoid alcohol, which can make mood swings worse. If you have an underactive thyroid, your doctor may prescribe thyroid medication.

Postpartum depression
Postpartum depression is often treated with counseling and medication.

* Counseling. It may help to talk through your concerns with a psychiatrist, psychologist or other mental health professional. Through counseling, you can find better ways to cope with your feelings, solve problems and set realistic goals. Sometimes, family or marital therapy also is helpful.
* Antidepressants. Antidepressants are a proven treatment for postpartum depression. If you're breast-feeding, it's important to know that any medication you take will enter your breast milk. However, various antidepressants can be used during breast-feeding with little risk of side effects for your baby. Work with your doctor to weigh the potential risks and benefits of specific antidepressants.
* Hormone therapy. Estrogen replacement may help counteract the rapid drop in estrogen that accompanies childbirth, which may ease the signs and symptoms of postpartum depression in some women. Research on the effectiveness of hormone therapy for postpartum depression is limited, however. As with antidepressants, weigh the potential risks and benefits of hormone therapy with your doctor.

With appropriate treatment, postpartum depression usually goes away within a few months. In some cases, postpartum depression lasts up to a year. It's important to continue treatment after you begin to feel better, however. Stopping treatment too early may only lead to a relapse.

Postpartum psychosis
Postpartum psychosis requires immediate treatment, often in the hospital.

When your safety is assured, a combination of medications — such as antidepressants, antipsychotic medications and mood stabilizers — may be used to control your signs and symptoms. Sometimes electroconvulsive therapy (ECT) is recommended as well. During ECT, a small amount of electrical current is applied to your brain to produce brain waves similar to those that occur during a seizure. The chemical changes triggered by the electrical currents can reduce the symptoms of depression, especially when other treatments have failed or when you need immediate results.

Treatment for postpartum psychosis can challenge a mother's ability to breast-feed. Separation from the baby makes breast-feeding difficult, and some medications used to treat postpartum psychosis aren't recommended for women who are breast-feeding. If you're experiencing postpartum psychosis, a team of health care providers will help you work through these challenges.

Prevention


If you have a history of depression — especially postpartum depression — mention it to your doctor as soon as you find out you're pregnant. Your doctor will monitor you closely for signs and symptoms of depression. Sometimes mild depression can be managed with support groups, counseling or other therapies. In other cases, antidepressants are recommended — even during pregnancy.

After your baby is born, your doctor may recommend an early postpartum checkup to screen for signs and symptoms of postpartum depression. The earlier postpartum depression is detected, the earlier treatment can begin. If you have a history of postpartum depression, your doctor may recommend antidepressant treatment immediately after delivery.

Lifestyle and home remedies

Postpartum depression isn't generally a condition that you can treat on your own — but you can do some things for yourself that build on your treatment plan. In fact, taking good care of yourself can help speed your recovery.

* Make healthy lifestyle choices. Rest as much as you can. Include physical activity, such as a walk with your baby, in your daily routine. Eat healthy foods — plenty of fruits, vegetables and whole grains. Avoid alcohol.
* Set realistic expectations. Don't pressure yourself to do everything. Scale back your expectations for the perfect household. Do what you can and leave the rest. Ask for help when you need it.
* Make time for yourself. If you feel like the world is coming down around you, take some time for yourself. Get dressed, leave the house, and visit a friend or run an errand. Or schedule some time alone with your partner.
* Avoid isolation. Talk with your partner, family and friends about how you're feeling. Ask other mothers about their experiences. Ask your doctor about local support groups for new moms or women who have postpartum depression.

Alternative medicine


Little research has been done on complementary and alternative therapies for postpartum depression. Although some data is available, it's not definitive.

If you'd like to try a complementary or alternative therapy for postpartum depression, share your wishes with your doctor. He or she can help you weigh the benefits and risks of specific therapies, such as:

* Acupuncture. Acupuncture helps promote deep relaxation, and sometimes even sleep. This may help relieve the fatigue that accompanies postpartum depression.
* Omega-3 fatty acids. Omega-3 fatty acids are known to support infant brain development during pregnancy. Some research suggests that omega-3 fatty acids — whether eaten in fish and other seafood or taken as a nutritional supplement — may help relieve postpartum depression as well.
* Massage therapy. Some studies suggest that massage therapy may be helpful for postpartum depression.
* Creative arts. Art, music and drama therapy have been suggested as possible ways to relieve postpartum depression, perhaps by providing a supportive, relaxed environment, offering new ways of expression or encouraging positive behavior changes.

Some studies suggest that the herb St. John's wort may be helpful for mild to moderate depression, although there's been no research published on St. John's wort and postpartum depression specifically. It's best to avoid St. John's wort if you're breast-feeding. St. John's wort may cause colic, drowsiness or lethargy in a nursing baby.
Remember, the best way to take care of your baby is to take care of yoursel


June 7, 2008

© 1998-2009 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.