Maternal hemorrhage, defined as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process, remains the leading cause of maternal mortality worldwide (1). Additional important secondary sequelae from hemorrhage exist and include adult respiratory distress syndrome, shock, disseminated intravascular coagulation, acute renal failure, loss of fertility, and pituitary necrosis (Sheehan syndrome).Hemorrhage that leads to blood transfusion is the leading cause of severe maternal morbidity in the United States closely followed by disseminated intravascular coagulation (2). In the United States, the rate of postpartum hemorrhage increased 26% between 1994 and 2006 primarily because of increased rates of atony (3). In contrast, maternal mortality from postpartum obstetric hemorrhage has decreased since the late 1980s and accounted for slightly more than 10% of maternal mortalities (approximately 1.7 deaths per 100,000 live births) in 2009 (2, 4). This observed decrease in mortality is associated with increasing rates of transfusion and peripartum hysterectomy (2-4).The purpose of this Practice Bulletin is to discuss the risk factors for postpartum hemorrhage as well as its evaluation, prevention, and management. In addition, this document will encourage obstetrician-gynecologists and other obstetric care providers to play key roles in implementing standardized bundles of care (eg, policies, guidelines, and algorithms) for the management of postpartum hemorrhage.

ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists

The effect of lactation on ovulation and fertility.

Levels of oxytocin (OT) and PRL were measured in plasma drawn before and during intermittent mechanical pump and tactile stimulation of the breast in five normal cycling women and 19 women in the third trimester of pregnancy. OT was significantly increased above baseline in response to breast stimulation in two of five cycling women and PRL increased in one of the two OT responders. In pregnant women, mean OT post nipple stimulation was significantly higher than pre nipple stimulation whereas PRL did not increase significantly. The response of OT to nipple stimulation occurred in 18 of 19 pregnant women compared to only two of five normal cycling women but the magnitude of the OT response in pregnant women was less than in cycling women or post-partum lactating women previously studied in this laboratory. In one non post-partum woman who induced lactation for the purpose of breast-feeding an adopted infant, OT and PRL were measured before and during mechanical pump and tactile stimulation before initiation of breast-feeding. OT increased during mechanical pump and tactile stimulation of the breast, as well as suckling, whereas PRL increased only in response to suckling. Levels of LH were measured in plasma every 20 min for 160 min at the following times: before initiation of breast-feeding, during induced lactation while breast-feeding, and 30 d after discontinuation of breast-feeding. Despite the development of oligomenorrhoea during the period of breast-feeding, levels of progesterone were not suppressed and LH was released in a normal pulsatile fashion.

Breast stimulation in cycling women, pregnant women and a woman with induced lactation: pattern of release of oxytocin, prolactin and luteinizing hormone.

Background While sexual activity in normal, healthy pregnant women is safe, concern regarding elements of the sexual act have led to restrictions in pregnancies experiencing complications that are frequently insufficiently addressed in clinical practice. Aim To comprehensively review the literature for evidence that supports or refutes specific sexual activity restrictions in high-risk pregnancy conditions. Methods A search of PubMed, MEDLINE, Ovid, UpToDate, Google Scholar, and Google for relevant publications related to any aspect of sexual activity affecting high-risk pregnancies complicated by history of pre-term delivery, shortened cervix, presence of cerclage, pre-mature rupture of membranes, placenta abruption, placenta previa, multiple gestation, or history of classical cesarean section was performed. Outcomes The scientific evidence on the pathophysiology of sexual activity and specific high-risk pregnancies, and their interaction. Results Despite expert opinion restricting sexual acts or intercourse, there are minimal published data that specifically address sexual activity in high-risk pregnancies. Conclusions Clinicians need to engage in conversations regarding specific sexual activity for patients experiencing complications in pregnancy. Recommendations for or against restricting sexual activity should be based on evidence-based guidelines. Significant advances in this area of obstetrics are necessary to make validated recommendations. MacPhedran S. Sexual Activity Recommendations in High-Risk Pregnancies: What is the Evidence? Sex Med Rev 2018;6:343–357.

Sexual Activity Recommendations in High-Risk Pregnancies: What is the Evidence?

A comparison between umbilical artery velocimetry and standard antepartum surveillance in hospitalized high-risk patients.

Contraction stress test by intermittent nipple stimulation.

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Contraction stress test by intermittent nipple stimulation.