Maternal obesity: Prevalence, ethnic differences, maternal complications and evaluation of body mass index cut-off values in an Asian obstetric population
Lay-Kok Tan1, Si-Ying Pang2 and Eng-Loy Tan1
1Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore
2Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Abstract
Introduction: Maternal pre-pregnancy obesity is a known risk factor for maternal complications. This study looks at the prevalence, ethnic distribution of maternal obesity, associations with maternal complications and examines the relevance of different body mass index cut-offs in predicting complications.
Design and methods: A retrospective review of women followed up at Singapore General Hospital over an eight-year period (2005–2012). World Health Organisation international and Asian cut-offs for BMI were used. Multiple logistic regression was applied to assess the association of maternal BMI with medical complications, adjusted for maternal age, ethnicity and parity.
Results: We identified 8843 mothers with singleton pregnancies. The prevalence of obesity was 12.2%. This ranges from 4.6% among Chinese women, 17.2% among Indian women, to 21.5% among Malay women. Malays comprised 65.4% of the obese group. Obesity is found to be strongly associated with existing diabetes mellitus (OR 7.81 (4.17–14.7)), essential hypertension (13.9 (7.52–25.6)), gestational diabetes mellitus (OR 2.53 (1.99–3.22)) and hypertensive diseases of pregnancy. With a BMI of 22–24 kg/m2, the relative risk of developing any maternal complication is 1.92 (p < 0.05) as compared to a BMI <20 kg/m2. A lower BMI cut-off of 23 and 27 kg/m2 for overweight and obesity, respectively is useful in identifying women at risk.
Conclusion: Obesity is a common problem in the obstetric population in Singapore and its prevalence varies between ethnicities. It is important to identify obese mothers to be at an increased risk of having complications. A lower BMI cut-off is recommended to better identify Asian women at risk.
Universal screening for subclinical hypothyroidism during pregnancy in a Jamaican cohort: Population reference ranges
Nadine Johnson1, Vikash Chatrani1, Anna-Kay Taylor Christmas1, Marvin Reid2, Eric Choo-Kang3, Monica Smikle4 and Rosemarie Wright-Pascoe5
1Department of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston, Jamaica
2Tropical Metabolism Research Institute, University of the West Indies, Mona, Kingston, Jamaica
3Department of Chemical Pathology, University of the West Indies, Mona, Kingston, Jamaica
4Department of Microbiology, University of the West Indies, Mona, Kingston, Jamaica
5Department of Medicine, University of the West Indies, Mona, Kingston, Jamaica
Abstract
Background: Subclinical hypothyroidism is associated with miscarriage, anaemia, gestational hypertension, placental abruption, premature delivery, postpartum haemorrhage, neonatal intensive care admission, and intelligence quotient (IQ) reduction in children. Screening for and treatment of subclinical hypothyroidism is controversial but possibly provides an opportunity to both reduce pregnancy complications and improve IQ. Study objectives were to obtain the first Jamaican data on the prevalence of subclinical hypothyroidism during pregnancy and establish gestational age-specific reference ranges for thyrotropin (TSH) and free thyroxine (FT4).
Method: A prospective cohort study was conducted from September 2009 to June 2012. Subjects were screened at 14 weeks’ gestation. Pregnancy specific reference ranges were generated according to The National Academy of Clinical Biochemistry Laboratory Medicine Practice (NACB) guidelines. Subclinical hypothyroidism rates were determined using calculated reference range (R1), non-pregnant references (R2), and previously recommended pregnancy ranges (R3).
Results: In total, 1402 subjects were recruited. Due to subject default, 784 consisting of 769 singletons and 15 twin pregnancies had their blood screened. The analysis was confined to singleton pregnancies. Mean gestational age at recruitment was 11 weeks, (range 6–19); 96% were screened at 14 weeks’ gestation. Mean TSH was 1.1 mU/L (0.0–7.5) and mean FT4 was 0.9 ng/dL (0.3–4.1). The prevalence of thyroid peroxidase (TPO) antibodies was 2.6%. Using 150 individuals who met the criteria as per NACB guidelines, the calculated reference ranges (R1) for TSH and FT4 were 0.03–3.17 mU/L, (mean ± standard deviation (SD), 1.1 ± 0.76), and 0.68–1.32 ng/dL, (mean ± SD, 0.93 ± 0.16), respectively. Prevalence of subclinical hypothyroidism using reference range R1, R2 and R3 was 1.4% (11/769), 0.5% (4/769), and 1.9% (15/769). Prevalence was significantly greater using R3 when compared to R2 (p = 0.011). TPO antibody prevalence was 2.6%. A significantly greater prevalence of TPO antibodies was found in subclinical hypothyroid subjects using all three reference ranges than in euthyroid subjects (∼ 25% vs. 2%., p < 0.05).
Conclusion: This study reports findings in an, Afro – Caribbean population. Our findings support the use of pregnancy specific reference ranges in our population. The 2.6% prevalence of TPO found concurs with previous findings reported in subjects of African descent.
Atrial fibrillation in a normal heart in pregnancy: Supplementing case report with registry data
Nadine Sauvé1, Évelyne Rey2 and Annabelle Cumyn2
1Division of Internal Medicine, Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
2Division of Obstetric Medicine, Department of Obstetrics and Gynaecology, CHU Sainte-Justine, Sherbrooke, Canada
Abstract
Background and objectives: Atrial fibrillation in a normal heart (AFNH) is rare in pregnancy and therefore poses a management dilemma. Only 17 pregnancies with AFNH occurring in 16 women have been published since 1960. The goal of this study was to compare our experience with the literature and add data to support management recommendations.
Methods: In 2011, after Ethics Review Board approval, GÉMOQ (Groupe d’Étude en Médecine Obstétricale du Québec) Registry of rare conditions in pregnancy was created. This Registry collects unusual cases in GÉMOQ members’ current practice. In 2012, an e-mail invitation was sent to all 132 members of the GÉMOQ to submit AFNH cases. Literature search was performed using Medline, Pubmed and Google Scholar from 1946 to 29 January 2014. Keywords used were atrial fibrillation and pregnancy.
Results: Fifteen episodes of atrial fibrillation (AF) in 11 pregnant women were submitted to the Registry (2012–2014). When compared to the published case reports, both series contained a majority of paroxysmal AF (93% vs. 94%), non-severe symptoms (no fetal consequence, syncope 1/32), and all but one woman had at least one echocardiogram. One woman in the Registry with persistent AF had a left atrial thrombus. However, certain differences were noted: (1) in triggers (classic triggers: Literature 47% vs. Registry 0%; minor triggers: Registry 33% vs. Literature 12%); (2) Recurrence in the same pregnancy and in a subsequent pregnancy occurred more often in the Registry group (27% vs. 6%) and (4 vs. 1), respectively; (3) Rhythm control was attempted in 44% of published cases, whereas 76% of patients had spontaneous cardioversion in the Registry; (4) A higher percentage of women were on either Aspirin (ASA) and/or low molecular weight heparin (LMWH) in the Registry (71% vs. 28%); and (5) A higher percentage of Cesarean deliveries performed for atrial fibrillation as the sole indication was observed in the literature cases (18% vs. 7%).
Conclusions: With the use of the GÉMOQ’s Registry, we were able, in a short period of time, to add 11 cases (15 episodes) to the published literature. Although recall bias may still play a role, we believe that this methodology adds significantly to the literature of AF in pregnancy. AF in a normal heart is probably more benign that clinicians believe and is well tolerated by both the mother and the fetus, often happening without classic triggers. Except in unusual situations, rate control with close monitoring is probably sufficient because spontaneous cardioversion happens frequently within 24 h. There is probably no indication to modify the timing/mode of delivery based on this arrhythmia in most cases. Although never reported previously in AF on a normal heart, stroke is possible at least in persistent cases as demonstrated by the presence of a left atrial thrombus in one of our cases.
Mechanical ventilation in critically ill pregnant women
SE Lapinsky1, K Austin1, JA Rojas-Suarez2, TM Crozier3, N Barrett4 and D Vasquez5
1Intensive Care Unit, Mount Sinai Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada
2Intensive Care Unit, Gestion salud clinic and Grupo de Investigación en Cuidados intensivos y Obstetricia, GRICIO, Universidad de Cartagena, Cartagena, Colombia
3Intensive Care Unit, Monash Medical Centre, Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
4Department of Obstetrics & Gynaecology, Monash Medical Centre, Clayton, Australia
5HIGA San Martin, La Plata, Buenos Aires, Argentina
Abstract
Objectives: Approximately 0.2% of pregnancies are complicated by respiratory failure requiring mechanical ventilatory support. Brief mechanical ventilation is not uncommon for operative delivery but little data exist to direct the management of the critically ill pregnant patient requiring longer term ventilatory support. This study describes mechanical ventilation in a cohort of critically ill pregnant women and evaluates the effect of delivery on respiratory function.
Methods: We retrospectively reviewed charts of pregnant women from four intensive care units (ICU) in four countries, who received mechanical ventilation for greater than 24 h. Data collected included demographics, ventilatory and respiratory measurements, and outcomes. Tidal volume and an estimate of respiratory system compliance (Vt/plateau pressure) were calculated for days 1 and 2 of ventilation. In women who delivered while on mechanical ventilation, maternal respiratory parameters were evaluated pre-delivery, and 2–5 h and 12–15 h post delivery. Data are presented as median (IQR), unless otherwise specified.
Results: Data were collected from 26 patients: median age was 30 (25–35) years and gestation at ICU admission was 25.4 (20–29) weeks. Duration of ventilation was 3 (2–7) days. Sedation and analgesia used included benzodiazepines (69% of patients), propofol (23%), and opiates (77%). Five patients (19.2%) received neuromuscular blockers and seven patients (27%) received vasopressors. Analysis of tidal volumes by predicted body weight showed a median of 7.6 (6.9–9.2) ml/kg and 7.8 (7–9.3) ml/kg on days 1 and 2, respectively. By actual body weight these volumes appeared smaller at 5.5 (5.1–6.7) ml/kg and 5.7 (4.5–7.2) ml/kg. Compliance estimates were 18.7 (15–26) ml/cmH2O and 21 (17–25) ml/cmH2O on days 1 and 2, respectively. Four women, ventilated with normal lungs (i.e. for neurological conditions), had a higher compliance at a mean of 38.3 ml/cmH2O. The median lowest oxygen saturation on days 1–2 was 94% (range 83–99%) and high PaCO2 was 36 mmHg (range 21–56). Seven patients delivered during the period of mechanical ventilation; One spontaneous stillborn delivery at 26 weeks and six cesarean sections (three for obstetric indications and three predominantly for worsening maternal condition). Some, but not all, patients demonstrated respiratory improvement post delivery, with a small mean improvement in oxygenation index (10.4–6.7) and in compliance (25.1–40.1 ml/cmH2O).There were three maternal mortalities in this cohort and three neonatal deaths.
Conclusions: This case series is unique in evaluating ventilatory measurements in a diverse cohort of pregnant women. We demonstrate a good maternal and neonatal outcome utilizing conventional ventilatory volumes, pressure limits and drug therapy. Delivery during mechanical ventilation had a modest effect on maternal respiratory mechanics and oxygenation.
Epidemiology of rheumatic heart disease in pregnancy: Australia and New Zealand
Michael John Peek1, G Vaughan2, K Tune3, F Mahony4, E Sullivan2 and RHD in Pregnancy Investigators5
1University of Sydney, Sydney, Australia
2University of NSW, Sydney, Australia
3Menzies School of Health Research, Darwin, Australia
4Auckland City Hospital, Auckland, Australia
5RHD in Pregnancy Investigators
Abstract
Objectives: Whilst overall a rare disease in Australia and New Zealand (ANZ), rheumatic heart disease (RHD) is disproportionate amongst Aboriginal and Torres Strait Islander, and Māori and Pacific Islander peoples and immigrants (particularly refugees) from sub-Saharan Africa and Asia. This disease of poverty and inequity has increased impact in pregnancy. The Australasian Maternity Outcomes Surveillance System (AMOSS) – a UNSW-based surveillance and research system that monitors rare and serious conditions in pregnancy – is conducting a four-year mixed-methods study of RHD in pregnancy (RHD-P). Nearly 300 participating sites across ANZ report monthly and complete web-based surveys on history, clinical pathways and outcomes for women with RHD-P during January 2013 to December 2014. Our objectives are to examine preliminary data provided to the AMOSS RHD-P quantitative study during the first 16 months of the study.
Methods: (1) Examination of survey data and (2) Australian surveillance data compared to hospital jurisdictional reporting of RHD-P. Eligibility includes pregnant women with RHD during 2013–2014 across ANZ with a rigorous inclusion review using World Heart Federation criteria for echocardiographic diagnosis of RHD and peer review confirmation by investigators. Up to four echocardiogram reports are submitted to the investigators for review and entry, and these provide critical information regarding inclusion and clinical pathways of the women.
Results: Based on jurisdictional data 2004/2005–2009/2010, the expected number of Australian cases ranges from 90–151 per annum. During the first eight months of the study, 51 eligible cases (Australia) and 43 (NZ) were notified. No women have died. A 2–3 month lag in notification occurs in over 33% of sites. Enhanced surveillance has been implemented in Northern Territory of Australia (NT) across perinatal, remote health, RHD control register and hospital data systems. A sub-study in NT has been developed to explore care pathways and health services for women excluded from the main quantitative study.
Conclusions: This prospective observational study forms the largest population-based research of women with RHD-P ever studied. It is examining the true incidence, distribution, epidemiology and impact of RHD-P, which has a profoundly disproportionate impact amongst Aboriginal and Torres Strait Islander, and Māori and Pacific Islander women. Study findings will enable benchmarking to identify key attributes of successful, culturally safe models of health care.
Maternal-placental syndrome and future risk of cardiovascular events in Swedish women with systemic lupus erythematosus: A population-based retrospective study
May Ching Soh1, Fadia Dib1, Magnus Westgren2, Lesley McCowan3, Catherine Nelson-Piercy1 and Dharmintra Pasupathy1
1King's College London, UK
2Karolinska Institute, Sweden
3National Women's Health & University of Auckland, New Zealand
Abstract
Background and aim: Women with systemic lupus erythematosus (SLE) develop cardiovascular events (CVE) at a younger age even in the absence of traditional cardiovascular risk factors. In pregnancy, women with SLE have more complications related to placental insufficiency that manifests itself clinically as pre-eclampsia, growth restriction, placental abruption or stillbirth, collectively known as maternal-placental syndrome (MPS). In unselected populations, the risk of cardiovascular disease is increased two-fold in women with previous MPS. This could be shared due to pathophysiological processes between MPS and future CVE that have been unmasked by the stress of pregnancy or pre-existing cardiovascular risk factors that are already present in young women who then develop MPS in pregnancy. It is not known if MPS further accelerates the development of future CVE in women with SLE. The aim of our study was to determine if MPS was associated with accelerated development of CVE in women with SLE.
Methods: This was a retrospective cohort study of parous women with SLE using linked population registries of birth, death and the national patient Registry from Sweden between 1973 and 2011. MPS was defined as hypertensive disorders of pregnancy, small for gestational (SGA) infant, placental abruption and stillbirth. CVE was a composite outcome of cardiovascular morbidity or mortality from coronary artery disease, stroke and peripheral vascular disease. Comparisons of survival were assessed using time-to-event analysis. Multivariate analysis used Cox’s regression model adjusted for year of delivery, number of inpatient admissions, duration of SLE and medical co-morbidities (renal disease, hypertension and diabetes).
Results: There were 7410 pregnancies in 3954 women. The prevalence of CVE was 9.9% (n = 390), with a median age of onset of 51 years (IQR 43–57). Women with CVE were more likely to have more inpatient admissions (median, 11 vs. 2), higher prevalence of medical co-morbidities (54.4% vs. 19.4%), longer duration of SLE (median, 12 vs. 9 years), higher prevalence of MPS (27.4% vs. 21.4%), SGA (16.5% vs. 12.4%) and intra-uterine death (IUD) (4.4% vs. 2.1%). The risk of CVE was increased in all women with MPS (adjHR 1.6; 95% CI: 1.2–2.0). Specific complications related to MPS including stillbirth (adjHR 2.1; 95% CI: 1.3–3.4), SGA (adjHR 1.6; 95% CI: 1.2–2.1) and hypertensive disorders of pregnancy (adjHR 1.7; 95% CI: 1.2–2.3) were associated with future CVE. A greater proportion of women with MPS (compared to those without MPS) developed accelerated CVE at 10 years after first delivery (3% vs. 1%, p < 0.05) and also at 20 years (8% vs. 3%, p < 0.05). These findings were independent of a history of maternal SLE at the time of pregnancy (p = 0.88).
Conclusion: In this high-risk cohort of young women with SLE, MPS was associated with increased risk of CVE. MPS has an independent effect on the accelerated development of CVE in women with SLE.
Combined exercise echocardiography and cardiopulmonary exercise testing at 14 and 24 weeks’ gestation
Henry Boardman1, Sarah French2, William Bradlow2, Lucy Mackillop2, Sally Collins1, Yvonne Kennworthy1 and Paul Leeson1
1University of Oxford, Oxford, UK
2Oxford University Hospitals NHS Trust, Oxford, UK
Abstract
Objectives: Cardiopulmonary exercise testing (CPET) is a well-established investigation used to stratify operative and anaesthetic risk as well as being predictive of cardiovascular morbidity and mortality. Pregnancy is a biological stress test and we hypothesized that CPET could risk stratify women with cardio-respiratory or metabolic disease during pregnancy. However, normal values in normal pregnancy are required before the predictive value of this test can be assessed in women with cardio-respiratory disease. This pilot study was designed to test the feasibility and tolerability of performing combined CPET and exercise echocardiography during pregnancy.
Methods: We prospectively recruited 10 women with a singleton pregnancy; all were healthy with no known medical conditions. Each participant attended at mean 14 + 1 (± 2 days) (visit 1) and 24 + 5 (± 3 days) (visit 2) weeks of gestation. At each visit, participants had a resting echocardiogram, fetal ultrasound scan and baseline blood sample collected. A stepwise incrementing CPET was then performed with a maternal echocardiogram at maximal exertion. A blood sample was collected at maximal exertion.
Results: The participants had a mean age at visit 1 of 35 years (± 4), six were nulliparous, body mass index was 24.3 (± 3.3). Combined CPET and exercise echo was successfully completed in all participants. There was no significant difference between visits for resting mean arterial pressure: 86.7 mmHg (± 9.6) at visit 1 and 86.5 mmHg (± 8.1) at visit 2 (p = 0.95) but resting left ventricular (LV) end diastolic volume increased from 77.3 ml (± 15.1) in visit 1 to 83.8 ml (± 17.2) in visit 2 (p = 0.008). Systolic function did not significantly change between visits, ejection fraction by Simpsons biplane: 63.8% (± 5.9) compared to 61.4% (± 4.6) at visit 2 (p = 0.36). Diastolic function measured by E/e′ was not significantly altered. During the CPET test, the peak workload achieved was similar at both visits: 165 W (± 35.7) in visit 1 and 170 W (± 36.9) in visit 2 (p = 0.51) as was VO2 max ml/kg/min: 28.5 (± 6.3) compared to 26.6 (± 2.9) (p = 0.34). Respiratory exchange ratio (RER) increased significantly between visits: 1.05 (± 0.05) compared to 1.11 (± 0.05) at visit 2 (p = 0.01). Lactates collected increased from 1.1 mmol/L (range 0.9–1.7) before maximal exercise to 6.4 mmol/L (range 4.5–8.8) after in visit 1 (p < 0.001) and from 1.1 mmol/L (range 0.5–2.8) to 6.0 mmol/L (range 2.2–7.7) in visit 2 (p < 0.001). All participants delivered healthy live neonates at term gestation; however, one participant developed pregnancy induced hypertension and two developed preeclampsia.
Conclusions: We successfully demonstrated that combined exercise echo and CPET study is well tolerated in pregnant women at 14 and 24 weeks’ gestation. We also demonstrated this combined test as a successful technique for capturing a wealth of metabolic and cardiac structural and functional data. Cardiac volumes increased between visits. RER increased which might suggest more familiarity with the test.
Current status of maternal mortality and morbidity from unsafe abortions in Steve Biko Academic Hospital
Hennie Lombaard1 and Patricia Duma Sebola2
1University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
2University of Pretoria, Pretoria, South Africa
Abstract
Aim: (1) To perform a confidential enquiry into severe acute maternal mortality and morbidity due to unsafe abortions, (2) to evaluate the resuscitation of patients with unsafe abortion and (3) to determine whether a strict protocol approach in managing patients with unsafe abortion has been adhered to.
Methods: Data were collected from medical records of every woman that fulfilled the criteria for severe acute maternal morbidity (Maternal near miss) and maternal death from unsafe abortion at Steve Biko Academic Hospital for the year 2008–2010.
Results: There were 38 cases of maternal near misses from unsafe abortions and 12 cases of maternal deaths in mothers who were less than 20 weeks pregnant. From the 12 maternal deaths, three were excluded because the mothers died from other causes unrelated to unsafe abortions. The mortality index in this study was 24%. The HIV status was positive in 32% of the maternal near misses and 33% in the maternal deaths cases. The HIV status was unknown in 39% and 33% of the maternal near miss and maternal death patients, respectively. The average Shock Index (SI) of the maternal near miss patients was above one pre-operatively in 61% of cases, improved in 58% of patients, deteriorated in 29% of patients and stayed the same in 5% of patients. The average SI of the maternal death patients was above 1 in 100% of cases pre-operatively or prior to death, improved in 44% of cases, deteriorated in 56% of cases. A speculum examination was performed in 11% of maternal death patients and 32% of maternal near miss patients. There were five (13%) of maternal near miss patients and two (22%) of maternal death patients who had a complete systematic evaluation. The average organ system affected was five organ system/patient in maternal death patients and two organ system/patient in maternal near miss patients. Patients that did not receive intravenous antibiotics as part of resuscitation were 21% of maternal near miss patients and 33% of the maternal death patients. Evacuation of the uterus was performed in 63% of the maternal near miss patients and 22% of the maternal death patients. Total abdominal hysterectomy was performed in 37% of the maternal near miss patients and 22% of the maternal death patients. Five maternal death patients (56%) did not get to theatre. The most common maternal near miss marker was the haematological system in the form of severe anaemia accounting for 60% of all the near miss markers.
Conclusion: Maternal death patients from unsafe abortion presented severely ill with an average of five organ system/patient which was more than double that of the maternal near miss patients (average of two organ system per patient). Management of patients with unsafe abortion especially those with septic shock remain sub-optimal as only five maternal near miss patients (13%) and two (22%) maternal death patients had a complete systemic evaluation according to the strict protocol approach.
How does HIV/AIDS affect maternal outcome in women with pre-eclampsia?
Hennie Lombaard1 and Edwin Assan2
1University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
2University of Pretoria, Pretoria, South Africa
Abstract
Aim: To establish if there were differences in presentation and outcome in HIV-positive pregnant patients with pre-eclampsia compared to HIV-negative patients with pre-eclampsia managed at Steve Biko Academic Hospital, Pretoria, South Africa.
Methods: The study period was 1 January 2009 to 31 December 2012. An electronic database of patients with pre-eclampsia who delivered at Steve Biko Academic Hospital labour ward was used to extract data on presenting variables and outcome variables. Presenting variables were maternal age, gestational age, parity, gravidity and maternal haemoglobin levels. Outcome variables that were assessed were caesarian section deliveries, postpartum haemorrhage, admissions to intensive care units (ICUs), maternal mortality rates (MMR). Differences between HIV-positive and HIV-negative pre-eclamptic patients were assessed in the case of categorical data by means of Chi-squared tests/Fischer’s exact tests and Independent t-tests for continuous data. Variables with p value <0.05 were considered statistically significant.
Results: The total number of births for this period was 12,474. The total prevalence of patients with pre-eclampsia was 11% (n = 1396). The number of HIV-positive women with pre-eclampsia was 230, and the number of HIV-negative women with pre-eclampsia was 1056. The prevalence of pre-eclampsia in HIV-negative women was 12% (n = 1056) compared to a prevalence of 11% (n = 230) in HIV-positive pregnant women with pre-eclampsia (p = 0.9). Results from presenting variables: (1) Pre-eclampsia was less common in HIV-positive patients between 15 and 24 years of age (n = 451, 42.7%, p < 0.001), (2) there were no differences in the distribution of HIV-positive to HIV-negative patients with pre-eclampsia in Gauteng, Mpumalanga and Limpopo provinces (p = 0.8), (3) women with pre-eclampsia who were HIV-positive had a higher mean parity and gravidity (p = 0.015 and p = 0.013, respectively) compared to HIV-negative women, and (4) HIV-positive women with pre-eclampsia also tended to have more anaemia (low haemoglobin levels) than HIV-negative women with pre-eclampsia (p = 0.06) which may have been due to the use of Zidovudine. The results of outcome variables showed: (1) HIV-positive patients on dual therapy < one month (n = 111) had a higher rate of caesarian sections for severe pre-eclampsia than HIV-negative patients (77.5%, n = 86, p = 0.02); (2) There were no differences in postpartum haemorrhage between the groups (p = 0.72) and no statistical differences in the surgical and medical management of postpartum haemorrhage (p = 0.8); (3) There were no statistically significant differences between the two groups in ICU admissions for HELLP syndrome (p = 0.54), renal failure (p = 0.35), severe pulmonary oedema (p = 0.2) or cerebral complications (p = 0.9); and (4) The MMR (January 2009–December 2012) for patients with pre-eclampsia at Steve Biko Academic Hospital was 136 per 100,000 live births.
Conclusion: There were differences in both presenting and outcome variables between the two groups. While there appeared to be no difference in terms of mortality and morbidity, these findings may have been impacted by the small number of either death or complications.
Radiological investigations performed in pregnant women for non-fetal reasons: A one-year retrospective study in a tertiary referral centre in the UK
Aarthi Rachel Mohan and Anita Banerjee
Guys and St Thomas' Hospitals NHS Foundation Trust, London, UK
Abstract
Background: There is evidence that there has been an increase in radiological investigations in recent years. Utilization rates (examinations per 1000 deliveries) of all radiological examinations increased by 106% from 1997 to 2006. The timing and appropriateness of these investigations in pregnant women are essential.
Objectives: To assess the number of radiological imaging investigations performed on pregnant women for non-fetal reasons in a tertiary referral centre in one year and to look at the percentage of positive test results compared to the total number of investigations performed and to evaluate the appropriateness of the investigation.
Methods: All radiological investigations performed in pregnant women in one year were retrospectively analyzed. The patients’ details were obtained from the radiology database and requests which included the terms ‘pregnant’ or ‘pregnancy’ were studied. The number of ultrasound scans for fetal reasons were excluded. The numbers of each type of investigation performed were calculated and the number of positive results recorded.
Results: During the one-year period of 2011, a total of 580 radiological investigations were performed in 461 pregnant patients, in a maternity unit with 6800 deliveries. Of the 580 investigations performed, 119 (20.5%) had positive results. The total number of radiographs performed was 106, out of which 81 included chest radiographs with 15 (19%) of these reported as a positive result. Fifteen computer tomography (CT) scans were performed (eight CT head scans, and seven CT pulmonary angiograms) and none had a positive result. Three of the nine (33%) MRI brain scans and one of the eight MR cerebral venograms were positive. Two of the 21 (10%) nuclear medicine ventilation-perfusion scans were positive. Only three of the 76 (4%) ultrasound lower-limb Doppler’s were positive for a venous thromboembolism. The total number of non-obstetric ultrasound scans of the abdomen was 163, out of which 25 (21%) was positive. The more specific organ investigations, such as pituitary and thyroid, provided a higher yield of positive results.
Conclusions: Diagnostic imaging is frequently used during pregnancy for non-fetal reasons. Our study showed that only one-fifth of the total number of non-fetal radiological investigations performed in pregnant women had a positive result. Careful consideration should always be given when exposing pregnant women to radiation. Modalities that do not use ionizing radiation, such as ultrasound and magnetic resonance imaging, should be preferred; however, no examination should be withheld when an important clinical diagnosis is under consideration. Even though precautions are used when carrying out radiation imaging, all efforts should be made to minimize the exposure of fetus and mother with consideration for the risks versus benefits for each investigation. We advocate standardized protocols for radiological imaging to be untaken to provide accurate and timely investigations for pregnant women.
Pregnancy outcomes after exposure to certolizumab pegol: Updated results from safety surveillance
Megan EB Clowse1, Douglas C Wolf2, Frauke Förger3, John J Cush4, Amanda Golembesky5, Laura Shaughnessy5, Dirk De Cuyper6, Kristel Luijtens6, Sarah Abbas7 and Uma Mahadevan8
1Duke University Medical Center, Durham, USA
2Atlanta Gastroenterology Associates, Atlanta, USA
3Department of Rheumatology and Clinical Immunology and Allergology, Inselspital, University of Bern, Bern, Switzerland
4Baylor Research Institute and Baylor University Medical Center, Dallas, USA
5UCB Pharmaceuticals, Raleigh, USA
6UCB Pharmaceuticals, Brussels, Belgium
7UCB Pharmaceuticals, Paris, France
8UCSF Medical Center, San Francisco, USA
Abstract
Objectives: The objective of this study was to provide an updated analysis of pregnancy outcomes in rheumatic patients (pts) after certolizumab pegol (CZP) exposure. CZP is a PEGylated Fc-free anti-TNF approved in 45 countries for the treatment of rheumatoid arthritis (RA) and/or Crohn’s disease (CD). CZP was also recently approved for psoriatic arthritis (PsA) and ankylosing spondylitis by the European Medicines Agency (EMA) and Food and Drug Administration (FDA), with the EMA also approving use in axial spondyloarthritis (axSpA).
Methods: The UCB Pharmaceuticals global safety database, designed to house and report adverse events for UCB Pharmaceuticals products, was searched for all medically confirmed cases of pregnancy through 28 March 2013. Reported pregnancies included women who became pregnant while participating in a clinical study and spontaneous post-marketing reports. The number of live births, spontaneous miscarriages and elective terminations for neonates exposed to CZP (maternal and paternal exposure) was examined. Congenital abnormalities, neonatal deaths and maternal demographics were also investigated.
Results: As of 28 March 2013, 309 CZP exposed pregnancies were reported: 285 were maternal exposure, 24 were paternal. For pregnancies with maternal exposure, the most common underlying maternal conditions for CZP treatment were CD (190/285) and RA (52/285), while the remaining 43/285 encompassed other indications, including axSpA and PsA. Pregnancy outcomes were available for 190 of these 285 pregnancies: 132 (69.5%) resulted in live birth, 36 (18.9%) in spontaneous miscarriage and 22 (11.6%) in elective termination. Of the 124 pregnancies with known outcomes in women with CD, 73% (91/124) resulted in live births, 20% (25/124) in spontaneous miscarriage and 7% (8/124) in elective termination. For the 42 pregnancies with known outcomes in women with RA, 61.9% (26/42) resulted in live births, 21.4% (9/42) in spontaneous miscarriage and 16.7% (7/42) in elective termination. Five congenital anomalies were reported, in four neonates, among all live births with maternal CZP exposure (n = 132): vesicoureteric reflux; congenital morbus hirschsprung disease and club foot; right aortic arch with aberrant left subclavian artery; mild unilateral hydronephrosis on antenatal ultrasound (described as healthy upon birth). None of these events were considered related to CZP by the treating physicians. A single neonatal death was reported after maternal exposure in one of a set of twins delivered before 26 weeks of gestation.
Conclusions: Updated analysis of pregnancy outcomes after exposure to CZP supports previous reports suggesting no apparent impact of maternal CZP exposure on pregnancy outcomes. Additional prospective data are required to fully evaluate the safety and tolerability of CZP in pregnancy.
Infants should not routinely be tested for postnatal anaemia following intrauterine exposure to azathioprine: Be wary of small studies with positive findings!
Manju Chandiramani1, Sabrina Jiwani2, Kate Wiles3 and Catherine Nelson-Piercy3
1Imperial College Healthcare NHS Trust, London, UK
2King's College London, London, UK
3Guy's and St Thomas' NHS Trust, London, UK
Abstract
Objectives: Azathioprine, an immune-modulating thiopurine, is commonly used to control and modify disease activity in pregnant women with systemic autoimmune diseases and to prevent rejection in solid organ transplants. Thiopurines have been used in pregnancy for several decades and are not teratogenic. Although rare, a potentially severe effect of thiopurine exposure is myelotoxicity (leucopenia, anaemia or thrombocytopenia). The exact mechanism of thiopurine-induced anaemia is unknown. It may be the result of drug-induced immune complexes damaging erythroid progenitor cells, inhibition of DNA synthesis and impaired production. A recent study showed a non-significant association between thiopurine exposure (n=30) and fetal anaemia (10/16 babies with haemoglobin (Hb) estimation),1 although there were many methodological flaws in this study. The authors failed to use gestation-specific ranges for neonatal Hb estimation and used median Hb values which when converted actually lie within the normal reference range. Estimation of neonatal Hb was not a primary outcome of the study. We sought to determine if there is an association with thiopurine exposure in utero and neonatal anaemia in our high-risk pregnant population.
Methods: We performed a retrospective cohort study of pregnant women receiving azathioprine therapy referred to Obstetric Medicine Clinics and delivered at two UK tertiary referral centres over a three-year period (2011–2013). Women who delivered at >24 weeks’ gestation were included in the analysis. Maternal demographics, medication use in pregnancy, indication for azathioprine use, delivery data (including Hb and white cell count (WCC) in labour) and fetal outcomes (including available Hb and WCC estimation within the first day of life if undertaken) were collected. Gestation-specific Hb concentrations were used to determine neonatal anaemia.2
Results: Fifty-eight women taking azathioprine in pregnancy who delivered at >24 weeks’ gestation were identified from a total population of 4987 women attending both clinics. The majority of women were on a daily dose of 100 mg of azathioprine (range 50–150 mg). Hb estimation was undertaken in 11 out of 59 (18.6%) neonates within the first day of life, mainly because of prematurity or concerns regarding maternal/neonatal sepsis. Neonatal Hb concentrations ranged from 14.1 g/dL to 19.6 g/dL, and were all within the gestation-specific normal ranges. Neonatal WCC concentration ranged from 5.4–30.8 × 109/L, which were outside of the normal reference range used for neonates, although this may be attributable to prematurity.
Conclusions: None of the neonates in this large retrospective cohort study were anaemic. Using gestation-specific normal ranges for Hb concentration, we were unable to reproduce the findings of a published study or demonstrate that the use of azathioprine in pregnancy is associated with neonatal anaemia. Until further prospective studies are undertaken with neonatal anaemia as a primary outcome and including an evaluation of maternal disease activity in pregnancy, infants should not be routinely tested following intrauterine exposure to azathioprine.
References
JharapBde BoerNKHStokkersP. Intrauterine exposure and pharmacology of conventional thiopurine therapy in pregnant patients with inflammatory bowel disease. Gut2014; 63: 451–457.a-0JoplingJHenryEWiedmeierSE. Reference ranges for hematocrit and blood hemoglobin concentration during the neonatal period: data from a multihospital health care system. Pediatrics2009; 123: e333–e337.a-1
The prevalence of raised tricuspid regurgitation velocity in pregnant women with sickle cell disease and its association with obstetric outcomes: An observational study
May Ching Soh1, Srividya Sankaran2, Natali AY Chung2, Eugene Oteng-Ntim1,2, Sue Robinson2, Jo Howard2 and Catherine Nelson-Piercy1
1King's College London, UK
2Guy's & St Thomas' NHS Foundation Trust, London, UK
Abstract
Background: In the non-pregnant sickle cell disease (SCD) population, a higher tricuspid regurgitant velocity (TRV) ≥2.5 m/s on transthoracic echocardiography (TTE) has been associated with an increased risk of death. In pregnancy, there are significant changes to cardiovascular physiology. It is unclear, if the same TRV value of ≥2.5 m/s is associated with adverse maternal or fetal outcomes.
Objectives: The objectives of our study were to determine the prevalence of TRV ≥2.5 m/s amongst pregnant women with SCD; and if it was linked to poor obstetric outcomes.
Methods: This was an observational cross sectional study between 2008 and 2012 of all women attending a specialized SCD Pregnancy Clinic. All women with SCD and singleton pregnancies with echocardiograms performed during pregnancy were included. They were excluded if lost to follow up or if there was an absent/inadequate tricuspid regurgitant jet on TTE to quantify TRV. The primary outcomes of interest were maternal mortality and preterm delivery (<37 weeks’ gestation). Other outcomes were stillbirth, length of gestation and customised birth weight centiles in the liveborn. Risk of an event was modelled on exact logistic regression. p-value < 0.05 was considered significant for all hypotheses tested.
Results: There were 34 pregnancies in 30 women. There were eight pregnancies in four women with TRV ≥2.5 m/s; the other 26 women had TRV <2.5 m/s. Two women with pulmonary hypertension diagnosed prior to pregnancy were advised to terminate and are not included in our analyses. The median age was 31.0 years (IQR 25–34 years). Prevalence of TRV ≥2.5 m/s was 13.3% (n = 8) of which only one had a reading of >2.9 m/s. Median TRV was 2.2 m/s (IQR 2.0–2.3). All women had preserved right and left ventricular systolic function. At the time of pregnancy, all women except one had good exercise tolerance (NYHA functional Class I–II). Baseline characteristics and medical comorbidities between the women with TRV ≥2.5 m/s and TRV <2.5 m/s were similar. There were no maternal deaths. Risk of preterm delivery was not significantly higher in those with TRV ≥2.5 m/s (OR 1.64; 95% CI: 0.12–15.25). Other obstetric and perinatal outcomes (customised birth weight centiles and Apgars) were similar in both groups.
Conclusion: Women with TRV ≥ 2.5 m/s had similar obstetric outcomes to women with TRV <2.5 m/s with no maternal deaths. While this is a small pilot study to determine the usefulness of echo screening in pregnant SCD women, it remains to be determined whether a TRV greater than 2.5 m/s should be used to risk stratify this group of parous SCD patients.
Neuromyelitis optica during pregnancy: A case report and review of the literature
Ahraaz Wyne, Patricia Smith, Bryon De France, Barbara Brennan and Geena Joseph
McMaster University, Hamilton, Canada
Abstract
Learning objective: Neuromyelitis Optica (NMO) or Devic’s disease is a rare, debilitating, neurologic disease characterized by optic neuritis and transverse myelitis. Thirty-four cases of de-novo Devic’s disease in pregnancy have been reported in the literature. We present on the diagnostic challenges, intrapartum deterioration and subsequent rapid postpartum improvement, of a 28-year-old women with Devic’s disease diagnosed during pregnancy.
Case presentation: A 28-year-old women G2P1 initially presented at nine weeks’ gestation with acute monocular visual loss and optic neuritis. Two months later, she began experiencing sharp left neck pain, left arm paresthesias and intractable nausea. At 25 weeks’ gestation, she experienced rapidly progressive bilateral upper extremity paresthesias, lower limb paralysis and urinary incontinence. MRI imaging revealed extensive signal abnormality extending from the medulla to the lumbar spine. Cerebrospinal fluid (CSF) antibodies against aquaporin-4 (anti-NMO Ab) were positive.She was treated with pulse methylprednisolone, plasmapheresis, intravenous immune globulin (IVIG), prednisone and azathioprine. Treatment only prevented further progression with minimal improvement in her symptoms. At 38 weeks, elective caesarean section under epidural anesthetic resulted in the birth of a healthy female infant. The patient was discharged to rehabilitation postpartum and had significant improvement. Three months later, she was standing independently, with mild residual incontinence. By 6- and 9-months, respectively, she was walking independently and had near complete recovery, with mild persistent dysesthesias. At 18-months postpartum, she was off all immunosuppressive therapy. Unfortunately in March 2014, nearly 2.5 years postpartum, she experienced a relapse, with paresthesias, lower limb paresis and hyperintensities on MRI spine. She has restarted azathioprine, prednisone and IVIG every three weeks, with gradual recovery and ability to ambulate with a walker.
Discussion: NMO is a devastating disease which requires a high index of suspicion for diagnosis, especially in pregnant patients. We conducted a review of the literature, finding 18 case-reports and case-series between 1990 and 2014, reporting on a total of 34 patients (mean age 33 years old) that experienced NMO during pregnancy. Gestation had a uniformly detrimental impact on the progression of symptoms in all cases and could be pathophysiologically correlated with maximal expression of placental aquaporin-4 receptors. Treatment regimens varied; ranging from pulse steroids to IVIG, azathioprine, rituximab and plasmapheresis. Of all the symptoms of NMO, optic neuritis appeared to be the most responsive to immunosuppression. Generally, there was poor response to any therapy intra-partum, similar to our case. On average, most patients experienced moderate recovery by a mean of one year postpartum; however by three years, relapse rates were as high as 80%. Epidural anesthetic or breast feeding did not seem to affect relapse rates. There is limited data to suggest a potentially poorer prognosis for de-novo NMO occurring during pregnancy. More prospective studies are needed to inform further research.
Coronary catheterization findings and disease management in women with premature acute coronary syndrome: Does a history of hypertensive disorder of pregnancy matter?
Emily McDonald1, Natalie Dayan1, Roxanne Pelletier1, Mark Eisenberg2 and Louise Pilote1
1McGill University Health Centre, Montreal, Canada
2Jewish General Hospital, Montreal, Canada
Abstract
Background: Hypertensive disorders of pregnancy (HDP) including pre-eclampsia and gestational hypertension are well-established risk factors for cardiovascular disease. Whether endothelial injury at the time of HDP has an impact on the type of coronary lesions and disease management in acute coronary syndrome (ACS) is unknown.
Objective: Our objectives were two-fold: first, to compare angiographic findings at the time of premature (< 55 years) ACS among women with and without a history of HDP. Second, to assess whether management of ACS differed according to history of HDP. Design: GENESIS-PRAXY is a cohort study into which 1213 men and women with premature ACS were recruited from 24 centers in Canada, one in the US and one in Switzerland, between January 2009 and April 2013. The present study included 306 women who had ever been pregnant. All patients underwent coronary catheterization and completed a self-report questionnaire to assess demographic and clinical characteristics. We compared catheterization findings, SYNTAX scores (a measure of angiographic coronary lesion complexity), and ACS management between 76 women with a history of HDP (27 with a history of pre-eclampsia and 49 with a history of gestational hypertension, classified into two distinct groups) to 227 women with prior normotensive pregnancies. Multivariable logistic regression was performed for variables that were associated with HDP on univariable analyses, and that were believed to be clinically significant.
Results: The median age of the cohort was 50 years (interquartile range: six years). Compared to women with previous normotensive pregnancies, women with previous pre-eclampsia were younger (p = 0.003) and were more likely to have thrombus on coronary angiography (p = 0.008). The multivariable logistic regression adjusted for obesity and ethnicity further supported this finding: women with previous pre-eclampsia had a three-fold increased risk of thrombus formation compared to women with previous normotensive pregnancies (95% CI: 1.29–7.60). Analyses comparing women with previous gestational hypertension to normotensive pregnancies revealed a greater likelihood of obesity, hypertension, diabetes, and previous gestational diabetes (p < 0.05 for all comparisons). Women with and without a prior history of HDP had similar ACS management profiles.
Conclusions: In our cohort of women with premature ACS, a history of pre-eclampsia and associated endothelial dysfunction appeared to be a risk factor for thrombus formation, while previous gestational hypertension was associated with a heavier burden of traditional risk factors. Management of ACS was not associated with prior HDP. These findings may have important implications for the prevention of cardiovascular disease.
Immune thrombocytopenia purpura in 269 pregnancies from two Canadian Centres providing high-risk obstetric care
Dongmei Sun1,2, Nadine Shehata2,3,4, Sandra Gregorovich5,6, Bryon De France5,6, Donald Arnold6,7, Prakesh Shah8,9 and Ann Kinga Malinowski4,10
1Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
2Obstetric Medicine, Mount Sinai Hospital, New York, USA
3Laboratory Medicine and Pathobiology, Mount Sinai Hospital, New York, USA
4Department of Medicine, University of Toronto, Canada
5Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University Medical Centre, Canada
6Department of Medicine, McMaster University, Canada
7Division of Haematology, McMaster University Medical Centre, Canada
8Department of Paediatrics, Mount Sinai Hospital, New York, USA
9Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada
10Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, New York, USA
Abstract
Background: Immune thrombocytopenia purpura (ITP) is estimated to affect 1–10 of every 10,000 pregnancies. Pregnancy poses unique challenges in the management of ITP due to potential maternal/fetal consequences of antenatal and peripartum bleeding. Treatment options are limited in comparison to the non-pregnant population, mostly given drug safety concerns.
Objective: This study aimed to review the management and outcome of pregnancies with ITP, particularly with respect to the maternal and neonatal response to intravenous immune globulin (IVIG) and corticosteroids, and to describe the platelet counts at which neuraxial anesthesia was administered.
Methods: A retrospective chart review was performed in two large Obstetric centers in Ontario: Mount Sinai Hospital (MSH) in Toronto and McMaster University Medical Center (MUMC) in Hamilton, from 1 January 2000 to 31 August 2012. At both sites, patients were identified through the Department of Medical Records. At MSH, patients were also identified through the Special Pregnancy Program Database.
Results: A total of 695 pregnancies affected by thrombocytopenia were identified. Of these, 269 pregnancies were in women diagnosed with ITP. Treatment was not required in 61% of pregnancies. IVIG was the initial agent in 45%, and complete/partial response was achieved in 47%. Corticosteroids were the initial agent in 51% of pregnancies, and complete/partial response was achieved in 40%. There were no fatal maternal bleeding events or hemorrhage into a critical organ. Clinically significant antenatal vaginal bleeding occurred in 2.2% of pregnancies. Of pregnancies that required treatment, the median platelet count at delivery was 72.0 × 109/L (IQR 49, 104.5). There were no neonatal deaths and no differences amongst groups in the rates of stillbirth, pre-term birth, birth-weight, or growth restriction. Platelet counts were not measured in 15% of infants. Of the neonates in whom platelet counts were available, 28% were thrombocytopenic (<150× 109/L) and of those, 30% were severely thrombocytopenic (< 50 × 109/L). The platelet count nadir occurred with the cord blood center in 33% of neonates, though in 3% it was encountered as late as day 6 postnatally. There were two cases of intracranial hemorrhage, although only one could be attributed to neonatal thrombocytopenia, accounting for 3% of all thrombocytopenic neonates but 8% of thrombocytopenic neonates who underwent an ultrasound examination. Of 156 patients who received neuraxial anaesthesia, the catheter was placed at platelet counts ≤ 70 × 109/L in 36%. The lowest platelet count prior to epidural catheter insertion was 45 × 109/L. No bleeding complications associated with neuraxial anaesthesia were recorded.
Conclusions: This multi-centre retrospective study demonstrated that the majority of pregnant patients with ITP did not require treatment. The risk of bleeding was low. Overall, neonatal outcomes were favourable; however, thrombocytopenia was encountered up to six days of life, suggesting that lengthier follow-up periods are required. Epidural catheters were inserted at platelet ranges lower than generally accepted without adverse events.
Variation in the relationship between gestational diabetes diagnosis and total gestational weight gain by maternal race/ethnicity
Rosette J Chakkalakal1, Tebeb Gebretsadik2, Ayumi K Shintani2 and Tom A Elasy1
1Department of Internal Medicine, Vanderbilt University, Nashville, USA
2Department of Biostatistics, Vanderbilt University, Nashville, USA
Abstract
Objectives: Compared to women without gestational diabetes (GDM), women with GDM have a higher pre-pregnancy body mass index and greater weight gain in the first trimester. Yet, small studies of GDM treatment effects have found that relative to their normoglycemic counterparts, women treated for GDM experience less weight gain following GDM diagnosis and less total gestational weight gain (GWG). Thus, treatment of GDM may have a beneficial “side effect” of controlling GWG. The purpose of this project was: (1) To determine the effect of a GDM diagnosis on total GWG in a large statewide database and (2) To determine if this effect is modified by maternal race/ethnicity.
Methods: We conducted a retrospective analysis of Tennessee birth certificate data for all infants born to non-Hispanic white (NHW), non-Hispanic black (NHB) and Hispanic adult women (age 18 and above) from 2004 to 2011. We excluded women diagnosed with diabetes prior to pregnancy. Using linear regression, we first examined the effect of GDM status on total GWG after adjusting for maternal race/ethnicity, pre-pregnancy body mass index, maternal age, highest maternal education level achieved, payment source for delivery, parity and tobacco use. We then tested the pre-specified interaction of maternal race/ethnicity and GDM status which was found to be statistically significant (p < 0.0001); the interaction term was therefore included in a second linear regression model used to predict total GWG by maternal race/ethnicity and GDM status.
Results: The final study sample included 531,638 women; GDM was diagnosed in approximately 5% of the sample. Seventy-two percent of women identified as NHW, 20% as NHB, and 8% as Hispanic. In the first model, a diagnosis of GDM was associated with an approximately 0.5 lb decrease in total GWG (p < 0.0001). However, after accounting for the interaction of maternal race/ethnicity and GDM status, we found that the negative association of GDM status and total GWG was present for NHW women but not for NHB or Hispanic women. NHW women with GDM gained approximately 1.6 lb less than NHW women without GDM (beta difference = −1.6, 95% CI: −1.8, −1.3) but NHB women with GDM gained approximately 4 lb more than NHB women without GDM (beta difference = 4.2, 95% CI: 3.7, 4.7) and Hispanic women with GDM gained approximately 1 lb more than Hispanic women without GDM (beta difference= 0.98, 95% CI: 0.24, 1.7).
Conclusions: We observed a decrease in total GWG among NHW women with GDM and an increase in total GWG among NHB and Hispanic women with GDM relative to their normoglycemic counterparts. Racial/ethnic variation in the association between GDM and total GWG could reflect differences in GWG prior to the diagnosis of GDM, treatment of GDM, and/or uptake of GDM treatment recommendations. Further research is needed to better understand reasons for this variation.
Mixed connective tissue disease and pregnancy: Maternal and foetal risks
Marie-Lou Tardif and Michèle Mahone
Centre Hospitalier de l’Université de Montréal (CHUM), Department of Internal Medicine, Quebec, Canada
Abstract
Background: Mixed connective tissue disease (MCTD) is an overlap autoimmune disease where patients have scleroderma and/or lupus and/or myopathy/polymyopathy symptoms with high levels of anti-RNP antibodies. There are few published case reports or retrospective studies concerning MCTD impact on maternal and foetal outcomes in pregnancy.
Objective: We present 10 cases and a systematic review to evaluate the maternal and foetal risks of pregnancy in women with MCTD.
Data sources: A Medline search was performed for the period of 1966 to December 2013 (Ovid and Pubmed databases).
Methods: We describe 10 cases including 12 pregnancies. A systematic review was conducted including cohort studies, case-control studies, case series and case reports. The study population consisted of pregnant women with MCTD.
Results: We found 41 women with 66 pregnancies in the literature. The average age including our data was 28.6 years, and the average duration of the disease was 5.5 years. Maternal mortality rate was 2.6%, the preeclampsia rate was 18%, the caesarean section rate was 31% and relapse rate was 27%. Foetal outcomes included prematurity in 49%, intrauterine growth restriction in 38%, neonatal lupus in 11% and a chondrodysplasia rate of 21%. Neonatal mortality was 10%. Women with relapse were more likely to have shorter duration of the disease and a higher risk of prematurity and foetal mortality.
Conclusion: MCTP is not a benign condition in pregnancy as the rate of relapse is 30%. These women and their foetuses have a higher risk of preeclampsia, prematurity and mortality. Disease activity seems to be a good predictor of pregnancy outcomes.
Guillain-Barre Syndrome in pregnancy: Worth a second look
Jayson M Potts1, Xavier Thompson2, Julianne van Schalkwyk1 and Wee-Shian Chan1
1BC Women’s Hospital and Health Centre, Vancouver, Canada
2Internal Medicine, University of British Columbia, Vancouver, Canada
Abstract
Objective: Intravenous immunoglobulin (IVIG) was first reported to treat pregnant patients with Guillain-Barre Syndrome (GBS) in 1997. With evidence of its non-inferiority to Plasma Exchange (PLEX), IVIG became the therapy of choice during pregnancy. GBS typically follows a progression of monophasic neurologic decline, plateau and slow recovery. Treatment related fluctuation (TRF) has been described where partial neurologic recovery occurs after IVIG therapy yet further deterioration ensues. We recently managed two cases of GBS in pregnancy. Each demonstrated initial improvement with IVIG and then further decline. We responded to our patients’ bimodal deterioration with further courses of IVIG but were uncertain of the evidence to support this management. This review was performed to better define the clinical course of pregnant patients with Guillain-Barre syndrome. We also reviewed the frequency, relevance, and existing management of patients with such a “bimodal presentation”.
Method: A systematic review of English and French literature was performed for papers published from 1997 to 2014.
Results: Thirty-two cases of GBS in pregnancy were identified. There were no maternal deaths. There was only one adverse neonatal outcome reported. This was a case of neonatal Guillain-Barre Syndrome, identified at 12 days of age, with no long-term sequelae. Sixteen (50%) deliveries were vaginal and delivery occurred at greater than 36 weeks’ gestation in 25 (78%) pregnancies. Twenty-nine (90%) women presented in the second and third trimesters; only one presented post-partum. Autonomic dysfunction occurred in 10 (31%) patients. Only five (16%) patients had treatment started within seven days of symptom onset. Of 13 patients, seven patients who had mechanical ventilation did not receive treatment prior to intubation. Seven (25%) patients had a rapid response to IVIG (within hours to days); and five patients who were in respiratory decline stabilized after IVIG and were not intubated. Most patients received single courses of therapy; 11 (34%) received IVIG and five (16%) received PLEX. Repeated courses of therapy were used in 12 (38%): Seven (22%) had IVIG alone while five (16%) received a sequential combination of IVIG and PLEX. The indication for repeated treatment was failure to improve in seven (22%) patients and TRF in five (16%). The dose of IVIG reported was universally 0.4 g/kg/day with no reported side effects.
Conclusions: Pregnant women with GBS syndrome have a favourable prognosis both for their pregnancy outcome and their long-term neurologic recovery. Treatment with IVIG, when administered early in the disease process, appears to improve the course of disease. Clinicians should monitor for TRF/bimodal deterioration that may benefit from repeat treatment. Future studies could investigate the consequence of altered pharmacokinetics of IVIG in pregnancy on TRF in pregnant patients with GBS.
Renal graft outcomes after pregnancy: Follow-up from the UK obstetric surveillance study
Kate Bramham1, Catherine Nelson-Piercy1, Kate Wiles1 and Marian Knight2
1Division of Women's Health, King's College London, UK
2National Perinatal Epidemiology Unit, University of Oxford, UK
Abstract
Introduction: Obstetric outcomes for women with renal transplants have recently been reported by a UK Obstetric Surveillance System (UKOSS) study. Pregnancy may be associated with an accelerated decline in graft function; however, reports of postpartum graft outcomes are limited by small numbers from single centres, and few are contemporaneous reflecting current therapeutic strategies. Risk factors for graft loss after pregnancy are unknown.
Methods: Women recruited in the UKOSS renal transplant study (Deliveries between 2007 and 2009) were matched with outcome data from the UK Renal Registry. Timing of graft failure was recorded and estimated glomerular filtration rate (eGFR) calculated before and after delivery. Follow-up period was defined as the time of delivery/miscarriage to date of most recent creatinine recorded or graft loss. Risk factors for graft loss were compared between those with functioning and failed grafts. A p value of < 0.05 was considered to be significant.
Results: 71/105 pregnancies (68%) in 69 women were matched with UK Renal Registry data. Fifteen (22%) women developed graft failure in the follow-up period. Three graft failures (20%) occurred within 12 months postpartum. Median time to graft failure was 26.6 months (IQR 13.3, 41.5). Maternal age, ethnicity, body mass index or pre-emptive or living donation had no influence on graft failure. Women with a failed graft tended to have a longer total time on dialysis before pregnancy than women with a functioning graft (37.5 months (20.7, 59.3) vs. 16.0 (3.7, 36.4), p = 0.075). Pre-pregnancy eGFR six months before conception was lower in women (52.6 mL/min/1.73m2 (42.6, 68.8) vs. 46.1 (31.5, 52.7)) and rate of change in eGFR between six and 12 months before conception tended to be greater in women with subsequent graft failure than those with graft survival. More than one previous transplant (8/15 (53%) vs. 7/54 (13%)) and pre-pregnancy proteinuria (5/13 (38%) vs. 4/34 (9%)) were also predictors of graft failure. Incidence of pre-eclampsia, maternal intensive care unit (ITU) admission, episodes of acute kidney injury, mode of delivery, gestation at delivery and infant birth-weight were not different between women with and without a failed graft.
Conclusion: Most women with renal transplants do not experience a decline in graft function after pregnancy. The majority of graft loss after pregnancy occurs over a year postpartum. Women with deteriorating graft function before pregnancy are at risk. Women with a second or third transplant are more likely to have graft failure than women with one transplant. Future work includes comparison with a nulliparous cohort matched for time of transplant and renal function.
Maternal, pregnancy and fetal outcomes in de novo anti-glomerular basement membrane antibody disease in pregnancy: A systematic review
Geena Joseph1, Benjamin Thomson2, William F Clark2, Doreen Matsui3, Michelle Hladunewich4, Amit Patel2 and Genevieve Eastabrook5
1Nephrology and Obstetrical Medicine, McMaster University, Hamilton, Canada
2Division of Nephrology, London Health Sciences Centre and Western University, London, Ontario, Canada
3Department of Paediatrics, Western University, London, Ontario, Canada
4Division of Nephrology and Obstetrical Medicine, University of Toronto, Toronto, Canada
5Department of Obstetrics and Gynaecoology, London Health Sciences Centre and Western University, London, Ontario, Canada
Abstract
Objectives: Anti-glomerular basement membrane (anti-GBM) antibody disease is a rare autoimmune disorder in which circulating Immunoglobulin G (IgG) antibodies are directed against an antigen normally present in the glomerular basement membrane of the kidney and the alveolar basement membrane of the lung. The clinical spectrum of disease includes rapidly progressive glomerulonephritis (RPGN) often resulting in end-stage kidney disease and/or pulmonary hemorrhage. Outside of pregnancy, anti-GBM antibody disease is associated with significant morbidity and mortality. There is limited knowledge regarding de novo anti-GBM disease in pregnancy. Anti-GBM disease in pregnancy may have worse pregnancy outcomes because anti-GBM antibiotics bind human placental antigen and are expected to cross placenta. We present the results of a systematic review and one unpublished case of de novo anti-GBM disease in pregnancy, reporting on clinical presentation, management, fetal, pregnancy and maternal outcomes.
Methods: A systematic review was performed to identify maternal, pregnancy and fetal outcomes in de novo anti-GBM disease in pregnancy. Studies were selected from PubMed, EMBASE, Cochrane Library databases, and conference proceedings, without language restriction.
Results: Data from eight patients were derived from seven case reports and one unpublished case. Most (6/8) patients presented after the first trimester. Acute kidney injury (5/8), anemia (5/8), hematuria (8/8) and proteinuria (8/8) were common. All patients were treated with immunosuppression. Half of the cases (4/8) were treated with immunosuppression during pregnancy. Immunosuppression regimens included various combinations of corticosteroids, cyclophosphamide, azathioprine, and plasmapheresis. Cyclophosphamide exposure occurred during pregnancy in a minority of cases (2/8) and was delayed to the post-partum period in three cases. All patients received plasmapheresis during their treatment course but the number of treatments varied dramatically (range 5–32). Azathioprine was used in the absence of cyclophosphamide induction in two cases. When hemodialysis was required during pregnancy (5/8), recovery of renal function was unlikely (1/5). While pulmonary involvement was common (5/8), no permanent damage was reported (0/8). The majority of cases ended in live births (6/8) although prematurity (6/6), intrauterine growth restriction (2/6), small for gestational age (4/6), and fetal complications (2/6) were common. When anti-GBM levels were tested in the living newborn, they were detectable (2/5), but no newborn renal or lung disease was reported (0/6). Complications in pregnancy included gestational diabetes (3/8) and preeclampsia (2/8).
Conclusions: Live births can be achieved in de novo anti-GBM disease in pregnancy, but are commonly associated with adverse maternal, pregnancy and fetal outcomes. Only with awareness of common presentations and management strategies can outcomes be optimized.
Obesity and quality of life during pregnancy: Preliminary results
Meireluci Costa Ribeiro1,2, Mary Uchiyama Nakamura1,2, Maria Regina Torloni2,3, Pedro Eduardo Mancini2, Bruna Maria Bernardi Forte2 and Rosiane Mattar1,2
1Department of Obstetrics- São Paulo Federal University (UNIFESP), Sao Paulo, Brazil
2São Paulo Federal University (UNIFESP), Sao Paulo, Brazil
3Internal Medicine Department, São Paulo Federal University (UNIFESP), Sao Paulo, Brazil
Abstract
Objectives: Obesity is a risk factor for hypertensive disorders of pregnancy and may also affect women´s quality of life. We aimed to assess the possible association between obesity and quality of life in Brazilian women.
Methods: Cross-sectional study conducted between August 2011 and February 2014 at the antenatal clinic of a public teaching hospital. So far, 206 healthy pregnant women between 14 and 40 weeks’ gestation were recruited: 100 were overweight and 106 were normal weight (pre-pregnancy body mass index >25.0 and 18.5–24.9 kg/m2, respectively). The World Health Organization Quality of Life-Bref (WHOQoL-Bref) questionnaire was used to assess quality of life, final scores range from 0 to 100, with higher scores indicating better quality of life. The Chi-square and Student’s t tests were used to compare variables between the two groups. p < 0.05 was considered significant.
Results: The main socio-demographic characteristics between the two groups were similar. Most of participants were of mixed race, multipara, married, catholic and employed. Total mean WHOQoL-Bref scores were similar in the two groups. For the 116 women in the second trimester of pregnancy, mean total scores were 65.3 ± 11.6 versus 65.2 ± 11.1 (p = 0.963), for normal versus overweight women, respectively. For those in the third trimester (n = 90), the scores were 62.0 ± 13.5 versus 62.2 ± 14.2 (p = 0.946), for normal versus overweight women, respectively.
Conclusion: According to these preliminary results of our ongoing study, being overweight does not seem to affect the quality of life of healthy women between 14 and 40 weeks of pregnancy, as measured by the WHOQoL-BREF questionnaire.
This study was funded by a grant from FAPESP – Fundação de Amparo à Pesquisa do Estado de São Paulo. Process n. 12/03670-4, 12/50225-6 and 12/11787-9.
Do overweight pregnant women have worse quality of sleep: Preliminary results
Rosiane Mattar1, Mary Uchiyama Nakamura1, Maria Regina Torloni2, Pedro Eduardo Mancini3, Bruna Maria Bernardi Forte3 and Meireluci Costa Ribeiro1
1Department of Obstetrics, São Paulo Federal University (UNIFESP), Brazil
2Internal Medicine Department, São Paulo Federal University (UNIFESP), Brazil
3São Paulo Federal University (UNIFESP), Brazil
Abstract
Objectives: Sleep quality and duration may be affected during pregnancy due to several hormonal, physiologic, physical and behavior changes that occur during this period. Obesity is a risk factor to breathing-related sleep disorders, especially in the third trimester, which have been associated with hypertensive disorders of pregnancy. We aimed to assess the possible association between obesity and sleep quality among Brazilian women.
Methods: Cross-sectional study conducted between August 2011 and February 2014 at the antenatal clinic of a public teaching hospital. So far, we have recruited 90 healthy participants between 28 and 40 weeks’ gestation: Fifty overweight and 40 normal weight women (pre-pregnancy body mass index (BMI) ≥25 and BMI 18.5–24.9 kg/m2, respectively). The Pittsburg Sleep Quality (PSQI) questionnaire was used to assess sleep quality; final scores range from 0 to 21, with total score ≥5 indicating poor sleep quality. The Chi-square and Student’s t tests were used to compare the two groups. p < 0.05 was considered significant.
Results: Main socio-demographic characteristics between the two groups were similar. Most of the participants were of mixed race, multipara, married, catholic and employed. Mean age was 28.1 ± 5.6 years, and mean gestational age was 34.1 ± 3.3. The proportion of overweight women with poor sleep quality (PSQI score ≥ 5) was significantly higher than that of normal weight women (88.0% vs. 66.7%, respectively, p = 0.0295).
Conclusion: According to our preliminary results, being overweight increases the risk for poor sleep quality in the third trimester of pregnancy.
This study was funded by a grant from FAPESP – Fundação de Amparo à Pesquisa do Estado de São Paulo. Process n. 12/03670-4, 12/50225-6 and 12/11787-9.
Effectiveness of placental growth factor as a screening tool for the prediction of severe pre-eclampsia in high-risk pregnant women
Snehal S Dhobale1, Revathi S Rajan2 and Kamini A Rao3
1Department of Reproductive Medicine, Milann –The Fertility Center, Bangalore, India
2Department of Fetomaternal Medicine Milann –The Fertility Center, Bangalore, India
3Department of Reproductive Medicine and Fetomaternal Medicine, Milann –The Fertility Center, Bangalore, India
Abstract
Background: Pre-eclampsia is associated with life threatening maternal and fetal complications like eclampsia, HELLP syndrome, placental abruption, fetal growth restriction and intrauterine fetal demise. Signs and symptoms of pre-eclampsia are not always the same and can present in atypical forms. Disease progression could be rapid, and clinical worsening is known to occur without premonitory symptoms. Diagnosing pre-eclampsia with today’s clinical guidelines based on high-blood pressure, proteinuria and premonitory signs and symptoms presents a challenge as these criteria are nonspecific and unreliable, leading to clinical uncertainty. So there is a clinical need for more specific markers that can directly measure the “root cause” (placental dysfunction resulting in angiogenic imbalance) of the disease per se. Placental Growth Factor (PlGF) is a marker of placental dysfunction and the levels decrease in the early onset, severe, pre-eclampsia and fetal growth restriction attributable to a placental cause. PlGF increases the diagnostic accuracy for the detection of pre-eclampsia due to its specificity for placental dysfunction between 20 and 34 weeks. PlGF has a better test performance compared to s-Flt/PlGF ratio (sFlt-1: soluble fms-like tyrosine kinase-1).
Methods: This is a single center observational study which enrolled 313 pregnant women attending the antenatal clinic at Milann between April 2012 and April 2014. 80% of this cohort were high-risk pregnancies with disorders such as thrombophilia, chronic hypertension, hypothyroidism, gestational diabetes mellitus and obesity. Subjects underwent a PlGF screen (by Alere Triage) between 20 and 24 weeks for the prediction of preeclampsia, and simultaneously underwent uterine artery Doppler screens. PlGF was considered to be screen positive when the value was < 5th centile for that gestational age. Gestational age based cut offs were incorporated as they have a better predictive value. All these pregnant women were followed up for outcomes which included preeclampsia, fetal growth restriction and intra-uterine fetal demise. PlGF screen positives were subjected to surveillance with appropriate medical interventions (antihypertensives, interval growth scans, fetal Doppler’s, modified biophysical profiles), customised to the severity of disease and gestation. The maternal and fetal outcomes of PlGF screen positive women were compared with outcomes of 100 historical controls who were delivered before the advent of PlGF screen at Milann.
Results: PlGF could predict pre-eclampsia in women with thrombophilia, p = 0.065 (15/26) and those with hypothyroidism cohort, p = 0.069 (18/26). The effective lead time with PlGF screening was markedly prolonged with significant mean rank difference by Mann-Whitney Test. The lead time was significantly more in the cohort with severe preeclampsia with p = 0.0001. A total of 62% of patients with PlGF screen positive status had a negative uterine artery Doppler screen. The average gestational age at delivery and birth weight had improved in patients with severe pre-eclampsia after being subjected to surveillance post PlGF screen positivity. Outcomes of patients with very low PlGF had improved with aggressive surveillance and monitoring. The effective lead time ranged between 4 and 7 weeks allowing delivery close to viability. PlGF in our study had a high-test sensitivity of 89.6% and specificity of 94.8% for early onset pre-eclampsia.
Conclusion: This strategy allowed the clinician for stratification of high-risk patients for surveillance enabling appropriate risk modulation (preferably by shift to a tertiary facility) to improve maternal and fetal outcomes. However, larger studies are recommended for further extrapolation of our results in the prediction of pre-eclampsia with PlGF in the second trimester.
Clinical characteristics and outcomes of jaundiced obstetric cases admitted to Omdurman maternity hospital, Khartoum, Sudan
Wafaa Abdelrazig Mukhtar Mohammed1,2, Enas Babiker MohiEldeen Gailii1,2 and Atif Bashir E Fazari1,2
1Reproductive and Child Health Research Unit (RCRU), University of Medical Sciences & Technology, Khartoum, Sudan
2Omdurman Maternity Hospital, Khartoum, Sudan
Abstract
Objectives: The aim of this study is to determine the clinical features, incidence, underlying causes, maternal and perinatal outcomes of jaundiced obstetric cases at Omdurman Maternity hospital from August 2013 to January 2014.
Methods: This is a descriptive, prospective, cross-sectional, hospital based total coverage study; which was conducted at Omdurman Maternity Hospital for Obstetrics & Gynecology in Khartoum, Sudan. This Hospital was established in 1957. It is a national service and training centre in obstetrics and recently for gynecology services. In 2013, the registered deliveries reached 35,486. After ethical approval, data on subjects meeting inclusion criteria were collected and analyzed using SPSS version 17.
Results: We reported 36 cases of jaundice in 18,969 delivered women, yielding an incidence of 1.9/1000. The main affected age group was 20–24 years. The majority of women were multiparous (55.6%). Close to two-thirds of cases 25 (69%) came from rural areas. The majority presented in the third trimester (69.4%). Twenty-six (72.2%) of cases had no antenatal care. Hypertensive disorders in pregnancy occurred in 13 (36%) cases and were complicated by HELLP syndrome in eight cases, acute fatty liver in two cases. The diagnosis was reached based on clinical grounds and laboratory findings in the majority of cases. Other diagnoses included hyperemesis gravidarum seven (19%), sepsis six (17%), hepatitis six (17%) and cholestasis of pregnancy four (11%). There were 14 (39%) maternal deaths. The remaining 22 patients (61%) were discharged in acceptable, improved conditions. The underlying cause of death was mainly hypertensive disorders in pregnancy (seven deaths), sepsis (three deaths), as well as Hepatitis, hyperemesis gravidarum. There were no deaths caused by cholestasis. The p value is significant for maternal death and hypertensive disorders in pregnancy (p = 0.015). One case of psychosis and another with tuberculosis were referred to appropriate specialists. Almost all cases received blood transfusion, and blood products were individualized according to the needs. Traditional healers’ intervention delays patients from seeking medical advice in time. Perinatal mortality was reported in (38.9%) of the cases.
Conclusion: Jaundice and pregnancy is a deadly combination and carries a grave prognosis for the mother and the fetus. In this study, incidence rate of jaundice is quite high and etiology varies. Early and timely diagnosis accompanied with a multidisciplinary approach to the management play an important role to save mother and fetus’ lives.
Prepregnancy counseling for women with acromegaly: More questions than answers
Angela Assal, Janine Malcolm, Heather Lochnan and Erin Keely
The Ottawa Hospital, Ottawa, Canada
Abstract
Learning objective: Although cases of pregnancy in acromegaly are rare, 174 reported, it is important that women with acromegaly who desire pregnancy receive preconception counseling. Our objectives were to review the literature of acromegaly and pregnancy and to identify the key challenges of preconception counseling. We recently had two women with acromegaly wishing to achieve pregnancy that we present below.
Case presentation: Our first patient was a 33-year-old women with acromegaly for 10 years. She was initially treated with transsphenoidal resection of her macroadenoma and maintained on Sandostatin LAR therapy. Her insulin-like growth factor 1 (IGF-1) levels were under control and she was asymptomatic from acromegaly. She desired pregnancy and approached our clinic for preconception counseling. She questioned the safety of Sandostatin prior to and during pregnancy, the safety of a vaginal delivery and the risk of congenital malformations. She successfully became pregnant and discontinued her Sandostatin at diagnosis of pregnancy. Her IGF-1 levels decreased throughout pregnancy, she had no return of acromegalic symptoms and had no gestational complications. She delivered a healthy female infant at 41 weeks weighing 3377 g and was able to breastfeed successfully. Our second patient, a 32-year-old women, was diagnosed with acromegaly after a work up for infertility. She underwent transsphenoidal resection of her macroadenoma. Post-operative magnetic resonance imaging (MRI) identified residual tumour burden. Preconception counseling regarding treatment options was discussed. She was initially managed with bromocriptine because of its safer profile in pregnancy. However, she had persistent symptoms and markedly elevated IGF-1 levels: 945 µg/L, which necessitated a switch to octreotide. Prior to conception her IGF-1 level was 748 µg /L. One year after diagnosis of acromegaly, the patient became pregnant and octreotide was discontinued. She had return of symptoms, including headache and diaphoresis; thus, octreotide was restarted at 12 weeks’ gestation to limit tumour growth. Her IGF-1 levels also decreased during pregnancy. She had no gestational complications and delivered a healthy macrosomic male, 4746 g, at 41 weeks and was able to breastfeed successfully. A post-partum MRI demonstrated a slight increase in the size of the macroadenoma to 34.4 × 23.2 × 20.8 mm from 32 × 21.5 × 18.3 mm on a pre-partum MRI.
Discussion: Preconception counseling is essential for patients with acromegaly who desire pregnancy. Important issues that were identified: impact of acromegaly on fertility, whether treatment plan should be modified if planning pregnancy, optimal timing of conception, if and when to discontinue treatment (prior to or after pregnancy), screening for associated conditions (e.g. diabetes, hypertension, sleep apnea), risk of progression of acromegaly/tumour growth during pregnancy, impact of acromegaly on pregnancy outcomes, surveillance during pregnancy (interpretation of GH, IGF-1 levels, MRI), overlap of normal pregnancy symptoms and acromegalic symptoms (e.g. Carpal tunnel), choice of method of delivery (risk of valsalva during vaginal delivery if significant residual tumour/tumour growth), and impact on neonatal outcomes and breastfeeding. Pregnancy can be safely achieved in patients with acromegaly. The scarcity of data limits the ability to provide evidenced-based recommendations to women around conception and pregnancy surveillance. Patients can be reassured that in most situations pregnancy proceeds without complications and that medical treatment can be used during pregnancy if necessary.
Validation of the Carescape V100 and the Bios Diagnostics 3AL1-3 E in pregnancy
Evelyne Rey1,2, Agnes Diltisheim1,2 and Driss Jaddour2,3
1Division of Obstetric Medicine, Department of Obstetric Gynecology, Montreal, Canada
2CHU Sainte-Justine, University of Montreal, Montreal, Canada
3Biomedical Engineering, Montreal, Canada
Abstract
Objective: To study the accuracy of the Carescape V100 (GE Healthcare) and the Bios Diagnostics 3AL1-3 E (Thermor Ltd) in normotensive and hypertensive pregnancies according to the European Society of Hypertension International protocol (2010) for the validation of blood pressure (BP) measuring devices.
Methods: The Carescape V100 and the Bios Diagnostics 3AL1-3 E are both upper arm automatic oscillometric monitors. In our hospital, the first one is employed ‘for clinic use’ and the second one ‘for self-measurement’. According to the validation protocol, BP obtained with these devices was measured three times, alternating with those obtained with the E-Sphyg2 monitor (American Diagnostic Corporation; hybrid monitor on manual auscultatory mode) used as a substitute of the mercury sphygmomanometer. Six BP differences/woman (tested device – E-Sphyg2) were calculated and the three smaller ones were kept for analysis. For the purpose of the study, the high-range systolic BP (SBP) was set at 150 mmHg instead of 160 mmHg. Thus, the BP ranges were: for SBP < 130 mmHg, 131–149 mmHg and ≥ 150 mmHg and for diastolic BP (DBP) < 80 mmHg, 81–99 mmHg and ≥ 100 mmHg.
Results: Thirty-five women were included for each device at a mean gestational age of 31.33 ± 0.8 weeks for the Carescape V100 and 30.9 ± 4.1 weeks for the Bios Diagnostics. Sixty percent of women participated in the validation of both monitors. Two women contributed only for SBP and two others only for DBP. Eleven women were included in each SBP and DBP ranges, except for SBP of 131–149 mmHg (n = 12), DBP of 81–99 mmHg (n = 12) and DBP ≥ 100 mmHg (n = 10) (Tables 1 and 2).
Demographic characteristics.
Carescape V100 (%)
Bios Diagnostics (%)
Hypertension
74.3
77.2
Caucasians
54.3
57.1
Pre-pregnancy obesity
25.7
14.3
Large cuff
34.2
31.4
Antihypertensive drugs
48.6
47.4
Validation results.
Part 1
≤5 (mmHg)
≤10 (mmHg)
≤15 (mmHg)
Grade 1
Difference (mmHg)
Pass requirements
Two of
73
87
96
All of
65
81
93
Carescape V100
SBP (n = 102)
50
68
91
Fail
8.6 ± 0.6
DBP (n = 99)
42
73
98
Fail
8.5 ± 0.7
Part 1
≤5 (mmHg)
≤10 (mmHg)
≤15 (mmHg)
Grade 1
Difference (mmHg)
Bios Diagnostics
SBP (n = 102)
86
101
104
Pass
0.2 ± 2.5
DBP (n = 99)
90
101
105
Pass
0.6 ± 1.9
Part 2
2/3 ≤5 (mmHg)
0/3 ≤5 (mmHg)
Grade 2
Grade 3
Pass requirements
≥24
≤3
Carescape V100
SBP (n = 34)
16
12
Fail
Fail
DBP (n = 33)
15
13
Fail
Fail
Bios Diagnostics
SBP (n = 34)
29
1
Pass
Pass
DBP (n = 33)
30
2
Pass
Pass
Conclusions: The Carescape V100 device should not be used in pregnancy while the Bios Diagnostics is suitable for blood pressure monitoring in pregnant women.
Midtrimester neurological effects of prenatal methadone exposure
Michael John Peek1, Meredith N Schulson1, Anthony JW Liu1, Ralph Nanan1, Tracey Bjorkman2, Ann Quinton1 and Kristy Mann1
1University of Sydney, Sydney, Australia
2University of Queensland, Brisbane, Australia
Abstract
Objectives: Methadone maintenance therapy is the standard of care in many countries for opioid-dependent women who become pregnant. Despite recent evidence showing significant neurodevelopmental changes in children and adults exposed to both licit and illicit substances in utero, data on the effects of opioids in particular remain scarce. The purpose of this study was to examine the effects of opiate use, in particular methadone, on various fetal cortical and biometric growth parameters in utero using ultrasound measurements done at 18–22 weeks’ gestation.
Methods: Head circumference, bi-parietal diameter, lateral ventricle diameter, trans-cerebellar diameter, thalamic diameter, cisterna magna diameter, and femur length were compared between fetuses born to methadone-maintained mothers and non-substance using controls.
Results: A significantly larger thalamic diameter (0.05 cm, p = 0.01) was observed in the opiate-exposed group. Thalamic diameter/head circumference ratio was also significantly raised (0.003 cm, p = 0.01).
Conclusions: We hypothesize here that the increase in thalamic diameter in opiate-exposed fetuses could potentially be explained by regional differences in opioid and serotonin receptor densities, an alteration in monoamine neurotransmitter systems, and an enhancement of the normal growth increase that occurs in the thalamus during mid-gestation.
Review of Australian hospital birth admissions of women with rheumatic heart disease
Michael John Peek1, G Vaughan2, E Sullivan2 and RHD in Pregnancy Investigators3
1University of Sydney, Sydney, Australia
2University of NSW, Sydney, Australia
3RHD in Pregnancy Investigators
Abstract
Objectives: Rheumatic heart disease (RHD) is a disease of paradox in Australia. Whilst overall rare, Aboriginal and Torres Strait Islander peoples have among the highest rates of RHD in the world. This preventable disease can have a serious impact in pregnancy, where increased cardiac demands often unmask undiagnosed RHD. Review hospital births of women with RHD (RHD-P) in selected Australian jurisdictions from 2004/2005 to 2009/2010, and determine trends over time.
Methods: Records of hospital births for women aged 15–44 with a diagnosis of RHD during 2004/2005 to 2009/2010 in selected Australian jurisdictions. Hospital separations with ICD10-AM code ‘Z37’ were counted as hospital births. RHD was defined as ICD10-AM code ‘I05’–‘I09’.
Results: The report demonstrates the disproportionate number of Aboriginal and/or Torres Strait Islander women with RHD, particularly in Northern Territory (NT) where 94% of women with RHD-P are Indigenous. It is highly likely that indigenous status is under-reported. Whilst rare (overall estimated rate of 4.5 per 10,000 births), RDH-P rates varied markedly from 1.3 per 10,000 births (Victoria) to 99 per 10,000 births in NT. Rates of RHD-P among indigenous women in NT were 54 times that of the overall rate in Australia. Numbers reported declined from 2004/2005 (n = 151) to 2009/2010 (n = 90), an overall decrease of 34% with 40% decrease in NT. However, a recent review of acute rheumatic fever/RHD in the NT showed evidence of a reduction in recurrence rate of acute rheumatic fever by 9%/year since 1997, but no decrease in the incidence of RHD.
Conclusions: It is inconclusive whether the reported downward trend in RHD-P represents a true decline or whether it is an artefact due to overall small numbers and probable under-reporting. The results reinforce the importance of an ANZ study of RHD-P with nearly 300 sites reporting data on history, clinical pathway and outcomes for women with RHD-P. The surveillance and research uses the Australasian Maternity Outcomes Surveillance System (AMOSS), a surveillance and research system that monitors rare, serious conditions in pregnancy. This prospective observational study forms the largest population-based research of women with RHD-P ever studied, and will examine the true incidence, distribution, epidemiology and impact of the disease in pregnancy.
A rare presentation of pre-eclampsia at 16 weeks’ gestation: The key is in the kidney
Aarthi Rachel Mohan and Catherine Nelson-Piercy
Guys and St Thomas' Hospitals NHS Foundation Trust, London, UK
Abstract
Learning objective: It is important to consider pre-eclampsia as a differential diagnosis in any pregnant woman presenting with new onset hypertension and proteinuria or seizures, regardless of gestation.
Case presentation: A 28-year-old woman from Nigeria, in her second pregnancy, presented with upper abdominal discomfort at 16 weeks’ gestation. She was found to have hypertension with a blood pressure of 160/104 mmHg. Urine dipstick revealed 3+ protein and 2+ blood. Blood tests showed a thrombocytopenia of 95 × 109/L (normal range 150–400 × 109/L) and a raised alanine transaminase (ALT) of 63 IU/L (normal range 10–40 IU/L) with normal haemoglobin, creatinine and bilirubin levels. Urine protein-creatinine ratio was raised and measured 179 mg/mmol. The patient was prescribed oral labetalol and nifedipine to control her blood pressure and was commenced on 75 mg aspirin. Transabdominal scan showed a monochorionic diamniotic twin pregnancy with fetal heart activity seen in both babies. Maternal kidneys, liver and gallbladder were normal. Over the course of 48 h, the platelet count dropped to 53 × 109/L and ALT level rose to 113 IU/L. A peripheral blood film showed approximately 1–2 fragments per high-powered field. Urine microscopy revealed dysmorphic red blood cells and urinary casts. The haematuria persisted and the proteinuria increased quantitatively over the following two days. The patient was given intravenous methylprednisolone and a platelet transfusion in order to undergo a renal biopsy under sedation, which showed glomerular endotheliosis. This confirmed a diagnosis of very early onset pre-eclampsia with no evidence of an active glomerulonephritis. An autoimmune screen including lupus antibodies was negative. There was a reduction in growth of both twins with estimated fetal weights of 220 g and evidence of cerebral re-distribution and reversed flow in the ductus venosus in one of the twins. The patient was counseled at length, and she consented to a termination of pregnancy at 19+3 weeks’ gestation. Labour was induced and she delivered both twins vaginally. Her blood tests normalized and she was discharged home four days after delivery on amlodipine to control her blood pressure.
Discussion: This case proved to be a diagnostic dilemma as pre-eclampsia is not usually diagnosed before 20 weeks of gestation. Clinically, our patient showed signs of pre-eclampsia and had no history or clinical signs of vasculitis. There were, however, signs of a glomerulonephritis including haematuria and urinary red blood cell casts. Our diagnosis of pre-eclampsia hinged on the renal biopsy results showing glomerular endotheliosis, which is specific for pre-eclampsia. Our case is one of only a handful of case reports of pre-eclampsia diagnosed before 20 weeks’ gestation, but this case confirms that very early onset pre-eclampsia is a diagnosis that must be considered in all pregnant women presenting with new onset hypertension and proteinuria or seizures, regardless of gestational age.
Neurofibromatosis and pregnancy outcome: Cases series study at Omdurman Maternity and Omdurman New Hospital, Khartoum, Sudan
Atif Bashir E Fazari1,2, RandaYahia Nagemeldeen Ali3 and Khalid Yassin4
1Reproductive and Child Health Research Unit (RCRU), University of Medical Sciences & Technology, Khartoum, Sudan
2Omdurman Maternity Hospital, Khartoum, Sudan
3University of Medical Sciences & Technology, Khartoum, Sudan
4Department of Obstetrics and Gynecology, Elnileen University, Khartoum, Sudan
Abstract
Objectives: The aim of this study is to determine the incidence, maternal and fetal outcome in cases of neurofibromatosis among pregnant women who attended the labor ward at Omdurman New hospital and Omdurman Maternity Hospital-Sudan.
Methodology: This is a descriptive, prospective, hospital-based total coverage ongoing study, which is conducted between Omdurman Maternity Hospital and Omdurman new hospital for obstetrical & gynecological services in Khartoum-Sudan. The study period started from October 2010 to April 2014. After ethical approval, data on pregnant women who met research criteria were collected and statistically analyzed.
Results: This case series show 25 women with well-established skin manifestations of neurofibromatosis. The age ranges between 19 and 31 years. Six women were primigravida, 14 were multipara and five grandmultipara. Out of the 25 cases; 16 cases (64%) had growth of new neurofibromas and enlargement of existing neurofibromas, while nine cases (36%) had no significant change. Unfortunately, nine cases only had antenatal booking, the rest had no antenatal care. Preeclampsia occurred in 11 cases (44%); seven of those had no risk factor. Eclampsia developed in three cases (12%) who were managed according to the protocol. One case of preeclampsia was complicated with facial palsy. Two of the cases developed gestational diabetes. Among the 25 cases, only one was a twin gestation; the rest delivered a singleton baby. Vaginal delivery was recorded in 14 (56%); seven (28%) cases with preterm deliveries; while cesarean section was performed in 11(44%) cases. Concerning the fetal anomalies, we reported two cases of anencephaly; one of them is a second twin case. And two cases of cleft lip; one of them accompanied with cleft palate. Intra uterine growth restriction is reported in five (20%) cases, four cases of unexplained intrauterine fetal demise and early neonatal deaths were reported in five cases.
Conclusion: Neurofibromatosis is one of the genetic diseases not commonly seen during pregnancy. The data about neurofibromatosis and pregnancy are still not well explored. Thus, neurofibromatosis is considered as high-risk condition in pregnancy, and adverse maternal and fetal outcomes are expected. It seems from this observational study that maternal and perinatal complications are seen more frequently in neurofibromatosis cases.
Obstetric outcomes of an Afro–Caribbean cohort following universal screening and treatment of subclinical hypothyroidism during pregnancy
Nadine Johnson1, Vikas Chatrani1, Anna Kay Taylor Christmas1, Marvin Reid2, Eric Choo-Kang3, Monica Smikle4 and Rosemarie Wright–Pascoe5
1Department of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston
2Tropical Metabolism Research Institute, University of the West Indies, Mona, Kingston
3Department of Chemical Pathology, University of the West Indies, Mona, Kingston
4Department of Microbiology, University of the West Indies, Mona, Kingston
5Department of Medicine, University of the West Indies, Mona, Kingston
Abstract
Objectives: Subclinical hypothyroidism is associated with an increased risk of obstetric complications. Restoration of normal thyroid function with thyroxine therapy has been shown to reduce the frequency of complications. The study aim was to determine if obstetric outcomes of thyroxine treated subclinical hypothyroid subjects identified from a screened cohort would be equivalent to that of patients with normal thyroid function.
Methods: This was a prospective cohort study. For the purposes of this study, subjects were considered to have normal thyroid function if thyroid-stimulating hormone (TSH) was 0.4–3 mIU/L and FT4 was 0.8–1.325 ng/dL with negative thyroid peroxidase (TPO) antibodies. Subclinical hypothyroidism was diagnosed as per previously recommended pregnancy specific values (Glinoer et al. 1998) i.e. TSH 2.5–3 mIU/L with positive TPO antibodies or TSH >3 mIU/L regardless of antibody status. Subclinical hypothyroid subjects were treated with thyroxine with the goal of reducing TSH to <2 mIU/L. Data were analyzed with STATA (StataCorp, USA).
Results: In total, 769 singleton pregnancies were screened. Mean gestational age at recruitment was 11 weeks, (range 6–19); 96% were screened at 14 weeks’ gestation. Of these, 511 (66%) had normal thyroid function. The prevalence of subclinical hypothyroidism was 1.9% (15/769), 26% (4/15) of whom were TPO positive. For subjects with subclinical hypothyroidism, mean TSH and FT4 were 3.79 ± 1.29 mIU/L and 0.92 ± 0.1 ng/dL, respectively. Eighty-one percent were treated according to the protocol and 54% were compliant. Mean gestational age at the first endocrine visit was 22.7 ± 2.7 weeks. A normal TSH was documented in 36% at a mean gestational age of 33 ± 2.94 weeks. Demographic and medical history risk factors were similar in both groups; however, subclinical hypothyroid subjects had a significantly greater incidence of a history of preterm premature rupture of membranes and preterm labour than normal subjects. No significant differences in maternal outcomes were found. Neonatal outcomes were also similar but subclinical hypothyroid subjects had a significantly greater incidence of necrotizing enterocolitis (6 vs. 0.4%, p < 0.05).
Conclusion: Treatment with thyroxine appeared to reduce obstetric complications as most maternal and neonatal outcomes of treated patients were similar to normal subjects. However, the prevalence of subclinical hypothyroidism in the cohort was low and compliance with therapy was just over 50%.
A case of status epilepticus in pregnancy: Cerebral venous sinus thrombosis versus eclampsia
Lindsay Porteous and Savas Menticoglou
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada
Abstract
Learning objective: Be able to recognize acute neurological symptoms in the pregnant woman, and decipher whether this is an exacerbation of a preexisting condition, an initial presentation of a non-pregnancy related disorder or the new onset of a neurological condition unique to pregnancy.
Case presentation: A nullipara presented at 12 weeks’ gestation with a one-month history of an unremitting new-onset headache. Magnetic resonance (MR) imaging revealed extensive cerebral venous sinus thrombosis with an area of venous infarction within the posterior temporal lobe. A suspected mastoiditis was also seen. In the hospital, low-molecular weight heparin and intravenous antibiotics were started. On day seven of her hospital stay, she had a tonic-clonic seizure that self-resolved. She was started on lamotrigine and remained seizure free. She was discharged on day 19 to continue her 8-week course of antibiotics. Follow-up MRIs showed some resolution of the thrombus. Blood pressures had been in the 100 s/60 s range throughout hospitalization and remained within normal limits for the remainder of pregnancy. At 27 weeks, the lamotrigine was stopped due to severe gastrointestinal upset. Her sister continued to administer her daily heparin injections. At 30 weeks, the patient presented with seizures. In the emergency department, she remained in status epilepticus despite infusions of midazolam, propofol and phenytoin. Her blood pressures were 160–180 s/100–110 s. She was given a 4 g intravenous magnesium load and sent to the intensive care unit intubated and ventilated for continuous electroencephalographic monitoring. After 1 h of status epilepticus, her seizures became controlled, and her blood pressures settled to 120/80 s. MR venography showed worsening thrombus throughout the sagittal and bilateral transverse sinuses, and the new finding of PRES (posterior reversible encephalopathy syndrome). The working diagnosis was seizures secondary to her pre-existing cerebral venous sinus thrombosis. She was started on a heparin infusion, and her sedation was titrated off. Obstetrics was consulted approximately 12 h later to assess fetal condition. The consultant noted the elevated blood pressures in the emergency department, nephrotic range proteinuria and low albumin. The consultant felt that eclampsia was the likely diagnosis. She was started on a magnesium infusion, and delivery by cesarean section was preformed 6 h later. Twelve hours after the cesarean section, and 36 h after the initial seizures, the clinical picture of HELLP syndrome developed (hemoglobin 58 g/L, platelets as low as 24 × 109/L, and transaminases over 1000 IU/L). Blood pressure control required intravenous labetalol. On post-operative day three, her bloodwork began to normalize, blood pressures were well controlled, and she began to recover her neurological function. She was discharged from hospital on day 22 having made a complete recovery.
Discussion: The differential diagnosis in critically ill patients with two plausible explanations for presentation can lead to difficult decision-making and patient management. Physicians have to make decisions in the presence of uncertainty, and multidisciplinary decision-making helps to make the best possible choices in ongoing care.
It’s baby time: Three successful pregnancies on intermittent hemodialysis
Michelle Haniff1, Catherine Clase1, Barbara Brennan2, Bryon DeFrance2 and Geena Joseph1
1Division of Nephrology, McMaster University, Hamilton, Canada
2Division of MFM, McMaster University, Hamilton, Canada
Abstract
Learning objective: Patients with end stage renal disease (ESRD) are usually amenorrhic and infertile with only 42% of women reporting at least one menstrual cycle after starting hemodialysis (HD). Conception is extremely rare in these patients with reported pregnancy rates between 1% and 7%. Survival of the fetus in this population has increased in the last decade with reported live birth rates ranging from 50 to 100%. There is a high rate of complications including growth restriction, prematurity, stillbirth, neonatal death, and preeclampsia. We present three successful pregnancies on intermittent HD.
Case presentations: Case 1: A 21-year-old-woman with reflux nephropathy on dialysis for eight months, whose pregnancy was discovered at four weeks and HD intensified to 18–21 h/week. The pregnancy was uneventful and delivered at 38 weeks; a healthy baby girl weighing 2780 g (10–50th percentile). Case 2: A 36-year-old woman with polycystic kidney disease, who in retrospect conceived prior to initiation of dialysis. Her pregnancy was discovered at 24 weeks and HD intensified to 24 h/week. The pregnancy was uneventful and delivered a healthy baby boy at 35 weeks weighing 2916 g (50–90th percentile). Case 3: A 32-year-old woman with focal segmental glomerulosclerosis on dialysis for 17 months, whose pregnancy was discovered at 18 weeks and HD intensified eventually to 27 h/week. Pregnancy was complicated by cervical incompetence, hypertension, and chorioamnionitis precipitating delivery at 30 weeks. The healthy baby girl weighed 1810 g (25–50th percentile). All patients were managed with intensified hemodialysis and a multidisciplinary team. Blood work was checked weekly to maintain predialysis urea <17 mmol/L, HCO3 18–22 mmol/L, K+ 3.5–5 mmol/L, Ca 2.2–2.5 mmol/L, PO4 0.8–1.6 mmoL. Hemoglobin was maintained between 100 g/L and 110 g/L with the use of Venofer, Darbepoetin and blood transfusions. Patients’ diets were liberalized to ensure adequate caloric and protein intake for daily dialysis and pregnancy. Blood pressures were monitored to maintain a blood pressure <140/90.
Discussion: These cases illustrate that successful pregnancies on HD are possible with intensification of HD prescription, careful management of hemoglobin and electrolytes. Pregnancies on dialysis remain high risk and require frequent monitoring. Close collaboration with a multidisciplinary team including nephrology, high-risk obstetrics, dietician, HD nurses, and social work is the key to successful pregnancies on hemodialysis.
A mimic of post-partum preeclampsia in a patient with panhypopituitarism
Sarah L Housman1 and Kenneth K Chen2
1Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, USA
2Division of Obstetric Medicine, Alpert Medical School of Brown University, Providence, USA
Abstract
Learning objectives:(1) To discuss the principles of managing panhypopituitarism during pregnancy and in the immediate post-partum period, (2) to discuss the principles of fluid management in the setting of coexisting preeclampsia and panhypopituitarism and (3) to discuss how the dosing of the different pituitary hormonal supplements affect fluid balance during the peri-partum and in the immediate post-partum period.
Case presentation: A 28-year-old lady was diagnosed with a pituitary macroadenoma in 2002 which required extensive neurosurgical debulking. She was subsequently rendered panhypopituitary and was maintained on stable doses of thyroxine, hydrocortisone and desmopressin for a number of years. She remained amenorrheic and sought to achieve pregnancy with the assistance of in vitro fertilization (IVF). She was successful with the first cycle of IVF and had her doses of hormonal supplements titrated throughout her pregnancy by an endocrinologist. She experienced mild gestational hypertension during the last few weeks of her pregnancy and had a normal spontaneous vaginal delivery at 39 weeks’ gestation. She was discharged without any complications on the second day post-partum. She presented two days later with severe headaches and an elevated blood pressure of 170/110 mmHg consistent with severe preeclampsia. She had significant fluid overload on admission which was treated with diuretics. She had self-administered stress-dose steroids just prior to her presentation. Her doses of hormonal supplements were reviewed more closely during her readmission and further adjustments in her doses were made prior to discharge. Her blood pressure stabilized promptly following her initial diuresis, and she required the use of low-dose calcium channel blockers over the next two weeks.
Discussion: In panhypopituitarism, hormonal supplement requirements increase throughout the course of pregnancy due to a multitude of factors including physiological changes in the target hormone levels, binding globulins and placental hormones. The maternal and fetal effects of under-replacement and over-replacement of each pituitary axis will be examined in detail. The complex interplay between each pituitary axis will also be discussed. The hallmark of preeclampsia in the post-partum setting is that of fluid overload which frequently requires the use of diuretics. The intricate relationships of how the individual and collective dosing of the different pituitary hormonal supplements (thyroxine, corticosteroids and desmopressin) affect fluid balance in this particular context will be discussed in detail.
Diagnosis and management in pregnancy of severe coronary artery disease due to pseudoxanthoma elasticum
David Ukiwe1, Catherine A Marnoch2, Philip N Baker3, James Drew4, Ali Khan1, Mark Webster5 and Lucille Wilkinson6
1Department of Cardiology, Waitemata District Health Board, Auckland, New Zealand
2Departments of Medicine and Obstetrics and Gynaecology, Waitemata District Health Board, Auckland, New Zealand
3Liggins Institute, University of Auckland, Auckland, New Zealand
4Green Lane Cardiothoracic Anaesthesia Department, Auckland City Hospital, Auckland, New Zealand
5Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
6Departments of Medicine and Obstetrics and Gynaecology, Auckland District Health Board, Auckland, New Zealand
Abstract
Learning objective: Pseudoxanthoma elasticum (PXE) is a rare-inherited connective tissue disorder, characterized by calcification and fragmentation of elastic fibres in the skin, eyes and arteries, including premature coronary artery disease (CAD).1 Case reports in pregnancy have described gastrointestinal haemorrhage, hypertension, subretinal haemorrhage and intrauterine growth restriction, with few reports on cardiac complications.2,3 We present a woman with PXE whose CAD was first diagnosed during pregnancy. The case highlights the importance of careful multi-system assessment, including investigations to assess CAD and other vascular complications. The management of severe CAD in pregnancy is discussed.
Case presentation: A 35-year-old primigravida presented at 12 weeks’ gestation with known PXE, diagnosed in puberty from skin lesions and retinal angioid streaks. She was asymptomatic with no other known complications and had typical skin changes in her neck, a right carotid bruit, and retinal angioid streaks. Investigations to stratify her cardiovascular risk included an exercise stress echocardiogram. She was asymptomatic but had echocardiographic evidence of inducible ischaemia in the right coronary artery territory at a low workload (stage 1 of the Bruce protocol). Coronary angiography confirmed severe, diffuse 3-vessel atheromatous coronary artery disease. Carotid artery Doppler ultrasound scan and cardiac magnetic resonance imaging were normal. Percutaneous or surgical coronary revascularization was anatomically possible but technically challenging. In consultation with interventional cardiology and cardiothoracic surgery, we elected to manage her severe CAD medically using aspirin and metoprolol with a plan to undertake percutaneous coronary intervention in the event of worsening symptoms or an acute cardiac event. Under close multidisciplinary team monitoring her pregnancy progressed normally, until she developed gestational hypertension at 37 weeks. Uncomplicated ventouse-assisted vaginal delivery of a healthy daughter occurred at 38 weeks’ gestation, after induction of labour using prostaglandin, syntocinon augmentation, patient-controlled epidural anaesthesia for analgesia and continuous cardiac monitoring. At six months postpartum, she was asymptomatic on medical therapy with cardiology follow-up to direct the need for revascularization in the future.
Discussion: PXE causes accelerated atherosclerosis with calcification of the internal elastic laminae, resulting in severe, premature CAD.1 Other vascular complications include peripheral vascular disease, cerebrovascular disease, hypertension, and placental insufficiency.2,3 To our knowledge, this is the first case report of an asymptomatic woman with PXE who had CAD diagnosed during her pregnancy. Careful history, physical exam, and targeted investigations aid in uncovering potentially life-threatening cardiovascular manifestations of PXE. Even in asymptomatic patients, stress imaging should be considered to exclude CAD. Once diagnosed, a multidisciplinary team management strategy of CAD in pregnancy includes tailored medical therapy, careful planning of delivery including anaesthetic considerations, and a well-considered revascularization plan in case of deterioration. This approach can be adapted to the assessment and management of women with other connective tissue diseases presenting in pregnancy.
References
LuoGDucyPMcKeeMD. Spontaneous calcification of arteries and cartilage in mice lacking matrix GLA protein. Nature1997; 386: 78–81.a-4BercovitchLLerouxTTerryS. Pregnancy and obstetrical outcomes in pseudoxanthoma elasticum. Br J Dermatol2004; 151: 1011–1018.a-5TanWCRodeckCH. Placental calcification in pseudoxanthoma elasticum. Ann Acad Med Singapore2008; 37: 598–600.a-6
A mysterious case of severe and sudden onset headache during pregnancy
Sophie Grand'Maison1, Florence Weber1, Michèle Mahone1, Marie-Josée Bédard1 and Ariane Godbout2
1Centre Hospitalier de l'Université de Montreéal (CHUM), Montreal, Canada
2Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
Abstract
Introduction: The differential diagnosis of headache in pregnancy is wide and severe, and sudden onset headache is a challenging condition. Rapid recognition of some conditions and treatment of possible associated endocrine disturbances are important to ensure maternal and fetal well-being.
Clinical case: A 33-year-old woman was admitted to the CHUM obstetrical ward at 39 weeks’ gestation with sudden onset of severe headache. Obstetrical history of this G6P3A2 woman revealed that she had previous pregnancies complicated by gestational hypertension and preeclampsia. The present pregnancy had been uneventful until she reported severe and sudden bilateral headache accompanied by nausea and dizziness 24 h prior to admission. No head trauma was reported, blood pressure and preeclampsia work-up were within normal values and the patient was discharged after 10 h of observation. She returned the next day with residual headache. Work-up was still normal. However, she fainted when leaving the hospital and was immediately readmitted for acute medical stabilization and further evaluation. A complete neurological exam at that point showed meningeal irritation and retinal exudate. Cranial nerve evaluation and lumbar puncture results were normal. A cerebral computerized tomography scan showed a prominent and slightly hyperdense pituitary gland of 12 mm in contact with the optic chiasma. Pituitary apoplexy was suspected, and an magnetic resonance imaging (MRI) performed seven days after headache onset confirmed sellar central hemorrhagic infarction and pituitary hyperplasia compatible with sub-acute pituitary apoplexy. Visual fields were normal. Labour was induced at 40 weeks under hydrocortisone coverage. She delivered a healthy 3.6 kg baby boy and began breastfeeding without problem. Initial hormonal work-up (FT4 12.3 pmol/L (10.0–23.0)), prolactin 391.0 µg/L (non-pregnant range: 3.0–29.0), cortisol 475.0 nmol/L (non-pregnant range: 119.0–618.0)) and biochemical results including sodium, potassium and glycemia were normal. At two months postpartum, endocrine work-up was still normal and a control MRI showed an important regression of pituitary size with a central remnant cyst of 6 mm.
Conclusion: Pituitary apoplexy is a rare cause of severe and sudden headache during pregnancy. Usually, the acute haemorrhagic infarction takes place in a pre-existing pituitary adenoma or more exceptionally, as this case suggests, in a physiologically enlarged gland. When it is suspected, it is essential to search for endocrine disturbance and treat hormonal deficiency since apoplexy can impair pituitary function. A multidisciplinary team approach (involving internists, endocrinologists, obstetricians and, when appropriate, neurosurgeons) can greatly reduce the morbidity and mortality that can result from this pituitary disorder.
Development of the maternal heart health clinic: An interdisciplinary cardiac disease in pregnancy clinic
Rshmi Khurana1, Winnie Sia1, Nazneem Wahab2, Debbie Germaine3, Jodi Wilkie3, Anelia Enstrom3 and Jonathan Windram4
1University of Alberta, Edmonton, Canada
2CK Hui Heart Centre, Edmonton, Canada
3Alberta Health Services, Edmonton, Canada
4Mazankowski Alberta Heart Institute, Edmonton, Canada
Abstract
Objectives: (1) To describe the rationale for developing a new interdisciplinary cardiac disease in pregnancy clinic, the Maternal Heart Health Clinic (MHHC), (2) to describe our first year experience in the implementation of the clinic and (3) to describe the challenges faced in establishing this clinic.
Background: Cardiac disease is a leading cause of maternal mortality/morbidity and is increasing in the developed world. The factors driving this rise include increasing maternal age, obesity and increased numbers of women with repaired congenital heart disease surviving into childbearing years. To respond to this challenge, we decided to establish an interdisciplinary clinic to provide appropriate care for these women. Prior to the establishment of the clinic, these women would be seen by the different specialties separately, resulting in multiple appointments and the potential for fragmented care plans.
Methods: We established an interdisciplinary clinic for women with cardiac problems in pregnancy. Patients have echocardiogram, electrocardiography and obstetric ultrasound in the morning. In the afternoon, they attend the clinic and are seen by an Obstetric Medicine physician and Cardiologist at the same time. They also have access to a pharmacist, nurse practitioner and dietician as required. After each clinic, the patients are reviewed in a group meeting with Maternal Fetal Medicine and anesthesiology as required. A detailed and comprehensive antenatal plan is developed as is a delivery plan in the third trimester. Management plans are communicated to the woman’s Obstetric Care Provider, family physician, her usual cardiologist as well as the labor and delivery suite.
Results: In the first 15 months of our clinic, we cared for 81 women with 71 pregnancies. Ten women were seen for a preconception consultation only and have not conceived. Fifty-three women have completed their pregnancies (two miscarriages) and 18 are still pregnant. The cardiac lesions seen included congenital heart disease (43%), arrhythmia (18%), cardiomyopathy (11%), valvular (11%), aortopathy (8%), ischemic (4%), pulmonary hypertension (1%) and other (5%). Challenges faced since the clinic’s inception include: (1) Lack of resources, (2) accommodating an increasing number of referrals, (3) engagement of care providers to refer to the team and (4) engagement from patients to be seen in a new clinic.
Discussion: Interdisciplinary clinics such as the MHHC can provide efficient and comprehensive care to pregnant women with cardiac disease. Advantages include: (1) the convenience of a “one stop shop” for fetal and maternal assessment of cardiac and other issues, (2) clear communication of patient management between the patient and the clinical team and other members of the multidisciplinary team and (3) coordination of a detailed delivery plan that is consistently available to the labor and delivery suite. Future plans for our clinic include qualitative studies to determine the perspectives of the stakeholders involved.
Clinical characteristics and outcome of septic obstetric cases admitted to Omdurman New Hospital, Khartoum, Sudan
Enas Babiker Mohieldeen Gailii1,2, Wafaa Abdelrazig Mukhtar Mohammed1,2, Mutasim S AbdAlla1 and Atif Bashir E Fazari1,2
1Reproductive and Child Health Research Unit (RCRU), University of Medical Sciences & Technology, Khartoum, Sudan
2Omdurman Maternity Hospital, Khartoum, Sudan
Abstract
Objective: The main aim of this research is to study the characteristics of septic obstetric cases at Omdurman New hospital during the period of study and to determine the incidence, morbidity and mortality of septic obstetric cases among the hospital intensive care unit (ICU) admission.
Methodology: This was a descriptive, prospective, cross-sectional hospital-based total coverage analytic study which was conducted from November 2012 to May 2013 at Omdurman New Hospital (ONH) for Obstetrics & Gynecology, Khartoum State-Sudan.
Results: Out of the 142 ICU admissions, 13 cases were diagnosed as severe sepsis and septic shock, resulting in an incidence of 9%. The main affected age group was 20–24 years, accounting for 46% of the cases. Mortality occurred in five of the studied cases (38.5%) and these cases represented around 20% of the hospital-registered mortality. Due to the small sample size that is typical of many studies of pregnant women, certain tests of significant are difficult to perform, although one and paired sample tests show a significant positive result.
Conclusion: Obstetric sepsis accounts for 38.5% of the ICU deaths and 20% of the hospital deaths. This mortality rate is considered high compared to reports from the developed world where mortality from sepsis is declining. These data reflect the situation in Sub Saharan countries where sepsis remains one of the leading causes of maternal mortality in our situation.
Peripartum Clostridium difficile infection: A single center experience from an obstetric hospital from 2008 to 2103
Niharika Mehta and Erica Hardy
Warren Alpert Medical School, Brown University, Providence, USA
Abstract
Background: Peripartum women, previously considered at low risk for Clostridium difficile infection (CDI), are now increasingly identified as a population that is vulnerable to this infection. This increased incidence among peripartum women correlates with the overall increased incidence of CDI in the general population.
Objectives: Our objective was to determine the incidence and clinical presentation of peripartum CDI at our institution in the past six years, in order to identify risk factors for CDI, complications related to disease and pregnancy, and recurrence rates.
Methods: A retrospective review of all women in the peripartum period testing positive for Clostridium difficile infection at Women & Infant’s Hospital from January 2008 to December 2013 was performed. Demographics and clinical characteristics including age, gravity and parity, prior antibiotic use, indication, laboratory data, treatment details, and pregnancy outcomes were recorded.
Results: A total of 22 women were identified over the period of six years – 14 were pregnant and eight were postpartum. Among 20 women, 18 had prior antibiotic therapy (no records were available for two patients). Among 22 women, 14 had prior hospitalization for various indications. Among the eight postpartum presentations, four were following cesarean section and four were following spontaneous vaginal delivery. Only two women were noted to have a recurrence of CDI and neither had a second recurrence. No cases required surgical intervention. No adverse pregnancy outcomes related to CDI were noted.
Conclusions: Almost all patients with CDI had prior antibiotic use, and in most cases this was short-term use (less than 48 h), for common postpartum indications such as chorioamnionitis and/or endometritis. The majority of women improved with oral metronidazole and did not relapse. These results support the data that, as in the nonpregnant population, antibiotic use remains a significant risk factor for development of CDI, even in this cohort, which was historically considered to be low risk. CDI is an emerging threat in peripartum women, and clinicians must maintain a high index of suspicion for CDI in pregnant or postpartum women with diarrhea, especially after recent antibiotic therapy, and even in the outpatient setting.
Clinical features of eclampsia and outcomes among cases managed at Omdurman Maternity Hospital from July 2013 to December 2013
Moses Maror Ayuel Rehan1,2 and Atif Bashir E Fazari2,3
1Bahr Elgazal University, Khartoum, Sudan
2Omdurman Maternity Hospital, Khartoum, Sudan
3Reproductive and Child Health Research Unit (RCRU), University of Medical Sciences & Technology, Khartoum, Sudan
Abstract
Objectives: Hospital-based study aimed at measuring the incidence of eclampsia, determining maternal mortality related to eclampsia and studying the clinical features, maternal and fetal outcomes of eclamptic patients.
Methods: The study is a descriptive, analytic, prospective, total coverage study that took place at Omdurman Maternity Hospital during the period of July 2013 to December 2013. The data collected and analysed using statistical analysis programme (SPSS).
Results: The study revealed that out of 18,968 deliveries 101 cases were identified and confirmed with eclampsia, which resulted in an incidence of 53 per 10,000 maternities. Most of the cases (70.3%) occurred antepartum, 27% occurred postpartum, and 3% occurred intrapartum; 51.5% of women were between 20 and 29 years of age, 28.7% were 30–39 years old, 17.8% were younger than 20 years of age and the rest were 40 years old and older; 63.4%, 28.7% and 7.9% were multipara, primigravida and grandmultipara, respectively. The study showed that the mode of delivery in the majority of eclamptic patients was cesarean section (70.3%) while 26.73% of the patients had a vaginal delivery and 2.97% had an instrumental vaginal delivery. There were 94% live births and the rest were perinatal deaths. The majority of patients survived (97%) and improved while 3% were registered as maternal mortality; 85% of the presented cases unfortunately had no antenatal care. Of the remaining 15% who had antenatal care, two-thirds did not regularly attend the clinic. The majority of eclamptic patients had no history of eclampsia (98%), had normal platelets count (84%), had normal renal function (89%), and normal liver function (89%).
Conclusion: Eclampsia occurs in our practice in a very high incidence as a sequel of hypertensive disorders in pregnancy, presenting as a major obstetric risk for the mother and the fetus as well. This study reflects some of the data about the outcomes of eclampsia which mandate prompt actions towards eclampsia and its complications.
Pregnancy and birth in women living with a single kidney: A retrospective review of 20 women
Samantha EJ Steele1, Jayne E Terry2, Louise M Page1 and Joanna C Girling1
1West Middlesex University Hospitals NHS Trust, North West London, UK
2St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
Abstract
Objectives: Kidney Research UK advises that those living with a single kidney may have an increased likelihood of developing proteinuria, hypertension or mild renal impairment and should have an annual General Practitioner (GP) review of blood pressure and urinalysis. It was our impression that pregnant women living with a single kidney were not aware of these issues. As preconceptual counseling and antenatal care offer a unique opportunity to adopt a life course approach to wellbeing, we sought to explore women’s understanding of the issues, document pregnancy outcome and devise a simple advice sheet for pregnant women with a single kidney.
Methods: Retrospective review of all women with a single kidney referred to the Obstetric Medicine Clinic at West Middlesex University Hospital, North West London, UK between April 2009 and April 2014, identified from a prospectively completed clinic database. Information was gathered from paper and electronic medical records, and pathology reporting. Main outcome measures were patient and GP awareness of healthcare issues related to living with a single kidney, renal parameters at booking, antenatal planning and pregnancy outcome.
Results: Twenty women were identified. The aetiology in 12 was congenital, seven trauma or surgery and one was a healthy kidney donor. They were from a number of ethnic origins and half were born outside the UK. The median age was 33 years; and median time with a single kidney was 26 years. Only one had received any renal input in adulthood. None had hypertension, proteinuria or abnormal renal function at booking. The most frequent complication was urinary tract infection (UTI): 11 women (55%) had at least one; in three it was complicated by pyelonephritis or a rise in serum creatinine. In six pregnancies pre-eclampsia, gestational hypertension or proteinuria occurred. The majority of babies were born vaginally at term, median birth weight 3274 g.
Conclusion: Whilst there are some reassuring data regarding outcome of pregnancy in healthy kidney donors, there is a paucity of evidence regarding appropriate pregnancy management in women with a single kidney from other causes. Our data support the view that in healthy women with a normally functioning single kidney, pregnancy outcome is generally considered to be favourable. However, pregnancy exposes the vulnerable single kidney to a number of stressors including hypertension, infection, hydronephrosis, iatrogenic trauma and hypovolaemic renal cell injury. None of the women were aware of the potential impact on their future wellbeing of living with a single kidney. Antenatal care (and pre-conceptual counseling) offers a unique opportunity for healthcare professionals to educate and empower women to adopt a life course approach to health, highlighting the importance of life-long renal protection, lifestyle modifications, measures to avoid renal tract infections and ongoing screening for hypertension and proteinuria. We will present our patient information leaflet.
Hyperemesis gravidarum as early pregnancy morbidity at Omdurman New Hospital Khartoum, Sudan
Atif Bashir E Fazari1,2, Hasouna Hamdi3, Rasha Eltayeb3 and Khalid Yassin4
1Reproductive and Child Health Research Unit (RCRU), University of Medical Sciences & Technology, Khartoum, Sudan
2Omdurman Maternity Hospital, Khartoum, Sudan
3Department of Obstetrics and Gynecology, University of Medical Sciences & Technology, Khartoum, Sudan
4Elnileen University, Khartoum, Sudan
Abstract
Objectives: To determine the incidence of hyperemesis gravidarum, hospital length of stay as well the morbidity and mortality related to hyperemesis gravidarum.
Methods: A prospective descriptive hospital-based total coverage study conducted in the period from January 2012 to July 2012 at Omdurman New Hospital Khartoum-Sudan. All cases of hyperemesis gravidarum admitted during this period were included in this study. A total of 167 cases were included. A data collection sheet was used to collect the data, then data were analyzed using SPSS.
Results: The incidence of hyperemesis gravidarum was 13% during this period with an average hospital stay of 2.2 days and readmission rate of 14.9% of cases. The majority was of the young age group: 37.1% of patients were 15–19 years old and 25.7% were 20–24 years of age. There was a decrease in frequency with increase in parity, where hyperemesis affected 1.8% of grandmultiparous, 43.1% of multiparous and 55.1% of primiparous women. Family history for hyperemesis was observed in 73.1%. Thirteen percent of women were smokers, and there was association between smoking and ketonuria; 85.6% of all women had a low socioeconomic status. Abnormal liver function tests were observed in 3.6%, and impaired renal function diagnosed in 10.2% of cases. Neurological deficit was described in 3.6% of patients.
Conclusion: Hyperemesis gravidarum has a high incidence and it causes great morbidity. The condition is more common in young patients. Hyperemesis decreased with higher parity. There is need for more education among the health care workers to highlight the magnitude of this health problem, and local guidelines should be formulated for the management of those patients.
Late diagnosis of primary hyperparathyroidism in pregnancy: Balancing risks for mother and fetus
Manpreet Gill, Winnie Sia, Rshmi Khurana, Carmen Young and Erin Toor
Department of Medicine, University of Alberta, Edmonton, Canada
Abstract
Learning objectives: (1) Discuss the importance of treating hypercalcemia in pregnancy near-term and (2) Recognize the risks of intraoperative fetal heart rate (FHR) monitoring during maternal surgeries.
Case presentation: A 31 year old was referred at 32 weeks’ gestation with a six-month history of nausea, vomiting, abdominal pain, and recurrent nephrolithiasis. Investigation revealed hypercalcemia at 3.03 mmol/L (corrected). A parathyroid adenoma was suspected based on elevated parathyroid hormone (PTH) of 18.9 pmol/L and a 1.6-cm thyroid pole lesion on ultrasound; the needle biopsy was nondiagnostic. Hydration and furosemide were ineffective at controlling her hypercalcemia and she continued to experience severe symptoms. Her management was discussed at a multidisciplinary conference which included Obstetrics, Obstetric Medicine, Neonatology, Anesthesiology, Perinatology and Otolaryngology. The decision was made to proceed to parathyroidectomy to relieve maternal symptoms and hope to prolong the pregnancy after surgery to deliver at a eucalcemic state. Parathyroidectomy was performed at 34 weeks’ gestation with continuous FHR monitoring. The procedure was prolonged but uncomplicated and successful. However, an emergency caesarean section was performed due to an abnormal fetal heart rate with normal baseline but absent variability. A 3230 g male infant was delivered and required brief resuscitation with positive pressure ventilation and intubation. The infant’s PTH was 1.8 (normal), ionized calcium was 1.1 (low), and he was asymptomatic. Both mother and baby had an uncomplicated recovery and were discharged 10 days post-operatively.
Discussion: Primary hyperparathyroidism can lead to adverse effects in both the mother and infant. Calcium is actively transported across the placenta via parathyroid hormone-related protein; particularly in the third trimester when the bulk of fetal calcium acquisition occurs. High maternal calcium concentrations, left untreated, will cause an initial hypercalcemic state in the neonate; causing endogenous PTH suppression that subsequently results in hypocalcemia. Infants can be asymptomatic or experience neuromuscular irritability, laryngospasm, tetany and seizures. Surgery is usually recommended over medical management in pregnancy for symptomatic women or those who have severe hypercalcemia. Ideally, non-obstetric surgery during pregnancy should be performed during the second trimester prior to fetal viability. When surgery is performed in the third trimester, the instinct may be to perform continuous FHR monitoring, if technically feasible, even though the evidence for its benefit or necessity is lacking. A decrease in the baseline FHR and variability are normal responses to anesthesia. Guidelines that provide specific criteria for intervening to deliver are lacking. The normal changes to the FHR due to anesthesia can easily be mistaken for pathology, potentially leading to unnecessary delivery. Our case highlights the difficulty in balancing maternal and fetal risks in the timing of surgery with late diagnosis of primary hyperparathyroidism. As well, it illustrates the potential hazards of continuous FHR monitoring in an anesthetized woman.
Pregnancy outcomes in women with idiopathic pulmonary arterial hypertension may be better with newer therapies and a multidisciplinary approach
Erinjit Toor, Rshmi Khurana, Dale Lien, Sujata Chandra, Erin Bader and Winnie Sia
Department of Medicine, University of Alberta, Edmonton, Canada
Abstract
Learning objective: Advancements in pharmacological therapy and a multidisciplinary approach may lead to improved pregnancy outcomes in patients with Idiopathic Pulmonary Arterial Hypertension (IPAH). We present two cases of IPAH and their management in pregnancy at our center.
Case 1: A 33-year-old woman was diagnosed with severe IPAH four weeks after the delivery of her second child. Her initial echocardiogram showed pulmonary artery pressures of 80 mmHg, with severe right-sided chamber enlargement and severe tricuspid regurgitation. She was started on bosentan, sildenafil, furosemide and warfarin. She had an unplanned pregnancy four months after the diagnosis and decided against termination despite thorough counseling about the high-maternal risk. Warfarin was switched to enoxaparin and bosentan and furosemide were discontinued. Sildenafil was continued, and bosentan was re-started in the second trimester. At 26 weeks’ gestation, she was hospitalized and intravenous (IV) epoprostenol was initiated due to deterioration in maternal status and increasing pulmonary artery pressures of 110–120 mmHg. A multidisciplinary team participated in developing a detailed delivery plan. She had a planned cesarean delivery and tubal ligation at 30 weeks for a healthy male infant weighing 1180 g. Post-partum, she had a prolonged stay in the intensive care unit. Her echocardiogram at six months postpartum continued to show signs of severe pulmonary hypertension. At 14 months post-partum, she died suddenly.
Case 2: A 22-year-old woman, with a history of IPAH since age 11 was referred to our clinic when she became pregnant. Her disease had been classified as severe but with the use of IV epoprostenol for five years, she was asymptomatic and her disease was classified as mild, with right ventricular systolic pressures at 50 mmHg. Ambrisentan was added at 23 weeks’ gestation. She had a planned cesarean delivery and tubal ligation at 32+4 week’s gestation for maternal deterioration and delivered a healthy male infant weighing 1995 g. She was managed post-partum in the intensive care unit. She continues to do well.
Discussion: IPAH is a contraindication to pregnancy as it carries high mortality risk to the mother.1 Data from case series show that the maternal mortality, which used to be 30% is now closer to 17%.1,2 The highest risk periods in pregnancy are between 24 and 28 weeks’ gestation, peri-partum and the puerperium.3,4,5 Despite counseling against pregnancy, some women may still conceive and want to carry on even after being made aware of the risks. Both of our patients deteriorated clinically during pregnancy and required escalation in therapy. We managed these two patients through a multidisciplinary approach,6 regular visits including assessment of symptoms, physical examinations, echocardiograms and initiation of additional therapies. Although these women should be discouraged from getting pregnant, successful outcomes can be achieved.
References
BedardEDimopoulosKGatzoulisMA. Has there been progress made on pregnancy outcomes among women with pulmonary arterial hypertension?Eur heart J2009; 30: 256–265.a-7a-8WeissBMZempLSeifertBHessOM. Outcome of pulmonary vascular disease in pregnancy: a systematic review from 1978 through 1996. J Am Coll Cardiol1998; 31: 1650–1657.a-9RobsonSCDunlopWBoysRJHunterS. Cardiac output during labour. Br Med J1987; 295: 1169–1172.a-10EasterlingTRBenedettiTJSchmuckerBCMillardSP. Maternal hemodynamics in normal and preeclamptic pregnancies: a longitudinal study. Obstet Gynecol1990; 76: 1061–1069.a-11Van OppenACStigterRHBruinseHW. Cardiac output in pregnancy: a critical review. Obstet Gynecol1996; 87: 310–318.a-12KielyDGCondliffeRWebsterV. Improved survival in pregnancy and pulmonary hypertension using a multiprofessional approach. BJOG2010; 117: 565–574.a-13
It’s hot in the tropics: Diverse presentations of a febrile illness secondary to Salmonella typhi infection in pregnancy
Kelly Yamasato1 and Janet M Burlingame2
1John A. Burns School of Medicine, University of Hawaii, Honolulu, USA
2Division of MFM, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA
Abstract
Learning objective: To report on pneumonia and pancreatitis associated with Salmonella infection in pregnancy.
Two case vignettes:Case 1. A 17-year-old nulligravida who recently arrived in Hawaii from the Marshall Islands. She presented at 32 weeks’ gestation with uterine contractions, vaginal bleeding, and cervical dilation. She noted subjective fevers for the few days prior to admission, and her initial temperature was 37.9°C. She was admitted for preterm labor and was administered betamethasone and magnesium sulfate tocolysis. On hospital day 2, the patient became febrile to 38.1°C, and she was started on ampicillin and gentamicin and given one dose of ceftriaxone for suspected pyelonephritis. She rapidly experienced increasing respiratory distress and chest computed tomography scan revealed extensive bilateral lung consolidation. She was intubated for her worsening pulmonary status with the diagnosis of Acute respiratory distress syndrome (ARDS). The patient continued to deteriorate, and due to persistent non-reassuring fetal heart tones she underwent cesarean delivery. Blood cultures returned pan-sensitive Salmonella typhi. Ceftriaxone was started with good response, and she was discharged on hospital 14 with ciprofloxacin. Blood cultures in the infant were negative. Case 2. A 21-year-old nulligravida from Hawaii who presented at 20 weeks’ gestation with fever, nausea, and emesis. Her examination was significant for a temperature of 39.5°C and epigastric tenderness. Serum chemistries revealed a mildly elevated aspartate aminotransferase (AST) and alanine transaminase (ALT) of 64 U/L and 67 U/L, respectively. Lipase was mildly elevated at 59 U/L with a normal amylase of 53 U/L. She was started on piperacillin-tazobactam. Abdominal ultrasound was negative for cholelithiasis or gallbladder wall thickening but suggestive of mild pancreatic inflammation. Blood cultures returned pan-sensitive S. typhi, and antibiotics were changed to ceftriaxone. Lipase peaked at 103 U/L, then trended down but remained mildly elevated. AST and ALT remained mildly elevated through the hospital course. The ceftriaxone was replaced with ampicillin due to the concern of the ceftriaxone contributing to pancreatitis. Her symptoms steadily improved, and she was discharged on hospital day 12 with amoxicillin. The patient delivered at 38 weeks of gestation. The neonate did not exhibit any obvious infectious sequelae.
Discussion:S. typhi infection is associated with a wide-ranging clinical presentation from a mild febrile illness to severe toxemia with multisystem involvement and in our case ARDS.1 The most common complications of this infection include gastrointestinal bleeding, intestinal perforation, and encephalopathy.1 Complications of Salmonella infection during pregnancy previously reported in the literature include intestinal perforation,2 vertical transmission with fetal loss or neonatal infection,1,3,4 and cholecystitis.5 Pneumonia1 and pancreatitis5,6 have both been associated with Salmonella infection. However, to our knowledge, these are the first reports of these complications occurring during pregnancy. These cases, therefore, may contribute to the body of information on diverse clinical presentation of Salmonella infection in pregnancy.
References
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Validation of the obstetric early warning score in critically ill patients in an upper-middle income setting
Angel Paternina-Caicedo1, Jezid Miranda1, Camilo Bello-Muñoz1, José Rojas-Suarez1, Andrew Levinson2, Ghada Bourjeily2 and Carmelo Dueñas1
1Department of Medicine, Universidad de Cartagena, Cartagena, Colombia
2Department of Medicine, Pulmonary and Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, USA
Abstract
Introduction: The aim of this study was to validate the usefulness of the obstetric early warning score (OEWS) in predicting maternal mortality in a cohort of critically-ill obstetric patients from Colombia.
Methods: A retrospective cohort study was conducted over a six-year period in an intensive care unit of a tertiary care, university-affiliated obstetric hospital. Women admitted to the intensive care unit were included if they were pregnant or within 42 days post-partum. The statistical and clinical Intensive Care National Audit & Research Centre ICNARC-OEWS were calculated based on data from the first 24 h of the critical care admission. We evaluated the performance of both clinical and statistical OEWS score using the area under the receiver operator characteristic (ROC) curve (AUC).
Results: During the study period of 2006 and 2011, a total of 50,897 deliveries occurred at our institution; 724 patients required intensive care unit admission resulting in an admission rate of 14.26 per 1000 deliveries. All 724 patients were included. Maternal mortality rate in this cohort was 4.13%. The most common cause of admission to the intensive care unit was hypertensive disorders of pregnancy (46%, 330/724); the most common cause of maternal mortality was post-partum hemorrhage 35% (11/29). Non-survivors had significant differences in systolic/diastolic blood pressure, temperature, heart rate, GCS and white blood cell count compared to those patients who did survive. The AUC for the clinical and the statistical OEWS was 0.83 (95% confidence interval (CI), 0.75–0.92) and 0.85 (95% CI: 0.78–0.91), respectively. For each increment in one unit of the clinical ICNARC-OEWS, the risk of dying increments to 147%. (OR 1.47; 95% CI, 1.30–1.65). For the statistical score, this risk increments to 146% (OR 1.46; 95% CI, 1.31–1.63).
Conclusion: When applied to a population in an upper middle income country, the ICNARC-OEWS performed less well than it did in a developed country. Differences are likely due to design, population and inherent limitations of the score.
Two cases of Guillain-Barre syndrome in pregnancy with treatment related fluctuation
Xavier Thompson1, Jayson M Potts2, Julianne van Schalkwyk2 and Wee-Shian Chan2
1Internal Medicine, University of British Columbia, Vancouver, Canada
2BC Women’s Hospital and Health Centre, Vancouver, Canada
Abstract
Learning objective: Two cases of Guillain-Barre syndrome (GBS) in pregnancy are used to emphasize the benefit of timely diagnosis and treatment. Women who develop GBS in pregnancy should have their neurologic recovery monitored closely to identify and manage treatment related fluctuation.
Case presentation: Patient one had bilateral limb weakness and paresthesias that progressed over five days, starting at 30 weeks + two days gestation. After presentation, she deteriorated over 12 h with worsening respiratory signs and symptoms. Within hours of receiving the first day of standard dose intravenous immunoglobulin (IVIG) (sdIVIG) her respiratory status stabilized, avoiding mechanical ventilation. This patient had risk factors for respiratory deterioration including bulbar symptoms, deterioration over less than seven days, and she required assistance to ambulate. After IVIG, she had rapid recovery in her peripheral strength and left the hospital seven days after admission, walking independently. Thirty-six hours after discharge, she was readmitted with bilateral facial palsy. A second course of sdIVIG was administered, and her facial palsy improved over subsequent weeks. There were no side effects from both courses of IVIG therapy. A healthy baby was delivered at term by caesarean section. Patient who had distal paresthesias that progressed over two days to limb weakness and facial palsy; symptoms started at 34 weeks’ gestation and followed a gastrointestinal infection four days earlier. Five days after the onset of symptoms, she received sdIVIG, stabilized and maintained the ability to ambulate with assistance. She returned to the hospital in labour at 36 weeks’ gestation. Having had a previous caesarean section, the same mode of delivery was chosen. Neuraxial anaesthesia was avoided owing to gestational thrombocytopenia. Six days after delivery, she was unable to ambulate or protect her airway, was readmitted and intubated. A second course of sdIVIg was organized just after intubation. While in intensive care unit, she had severe bradycardia requiring intravenous beta-agonists. Neurologically, she recovered fully and was asymptomatic 10 months after presentation.
Discussion: GBS is an immune-mediated, peripheral nerve disorder that is frequently triggered by a preceding infection. It is recognized by albuminocytologic dissociation within the cerebrospinal fluid, typical Electromyography findings, and acute or subacute neurologic deterioration over days to weeks. A standard dose of IVIG, given as 0.4 mg/kg/day over five days, is first-line treatment in pregnancy. However, the optimal dose and duration of IVIG therapy are uncertain. The benefit of repeat courses of IVIG is currently being studied. Treatment-related fluctuation (TRF), defined as improvement or stabilization post treatment and then further deterioration, occurs in approximately 10% of cases of GBS. This is described as natural progression of GBS altered by therapy. Our cases demonstrate TRF with deterioration, treatment, improvement, and further deterioration. Objective tools for neurologic assessment in GBS exist and may identify treatment-related fluctuation.
Conclusion: Treatment-related fluctuation is demonstrated in pregnant patients with GBS, and frequent objective monitoring of neurologic status can identify those who may benefit from repeat therapy.
High-output cardiac failure due to pregnancy with reversal of pulmonary hypertension in a congenital arteriovenous malformation
Jose Rojas-Suarez1, Hector H Saavedra Orozco2, Walter Ojeda Dancur2, Orlando Borre Arrieta3 and Elayne M Vasquez Medrano3
1Department of Obstetrics and Gynecology, Universidad de Cartagena, Intensive Care and Obstetric Investigation Group (GRICIO) and Clinica Gestion Salud, Cartagena, Colombia
2Department of Obstetric & Gynecology, Universidad de Cartagena, Cartagena, Colombia
3Department of Obstetric & Gynecology, Universidad de Cartagena, Clinica de maternidad Rafael Calvo, Cartagena, Colombia
Abstract
Learning objective: With the exception of infants and newborns, arteriovenous malformations rarely cause congestive heart failure. Pregnancy is considered a high-output cardiac condition. This may hypothetically exacerbate cardiac failure in congenital vascular malformations, leading to secondary pulmonary hypertension by excessive pulmonary blood flow, mimicking idiopathic pulmonary arterial hypertension (PAH). We present an unusual case of a pregnant patient with evidence of high-output cardiac failure secondary to a congenital arteriovenous malformation in the scapular region and review the hemodynamic effects of pregnancy in this preexisting condition.
Case presentation: A 23-year-old woman, G2P1A0, 36.5 weeks of gestation, presented to our hospital with a 3-month history of exertional dyspnea and orthopnea. She was asymptomatic until three months prior to presentation. She describes a congenital cutaneous lesion in her scapular region with a significant increase in size during previous pregnancy and now with the onset of symptoms. On physical examination, the most striking features were an increased jugular venous pressure, a 2/6 systolic murmur at the left upper sternal border, a cutaneous lesion in scapular region of 12 × 10 cm, bright red, raised, warm with presence of a thrill and gross varicose veins in the lower limbs. Fetal examination was normal. Chest x-ray showed cardiomegaly. Echocardiography revealed normal ejection fraction (66%), mild bi-atrial and right ventricular dilation with significant tricuspid regurgitation and mild pulmonary hypertension (38 mmHg). An abdominal ultrasound shows normal kidneys with large dilated veins on both sides. Clinical diagnosis of high-output cardiac failure was suspected, and congenital arteriovenous fistula in scapular region considered as possible origin. The medical board considers termination of pregnancy and postpartum angiography of right subclavian artery. The patient was transferred to the intensive care unit for monitoring. She underwent cesarean section, and giant uterine vascular dilation was evident during surgery. A 3100 g healthy male newborn was delivered with no surgical complications. A postpartum angiography of right subclavian artery shows the presence of an arteriovenous malformation located in the deltoid region with main branches of the right subclavian artery, and a venous drainage through the subclavian vein with increased flow to the superior vena cava and right atrium. The patient improved a few days after delivery. An echocardiogram performed two weeks postpartum shows a dramatic improvement in right cardiac filling pressures and a reversal of pulmonary hypertension. Delayed surgical obliteration by selective arterial embolization was planned at four weeks postpartum. Unfortunately, the patient did not return for follow up.
Discussion: A high index of suspicion of arteriovenous malformation should be maintained in pregnant women with vascular malformations if symptoms of heart failure are present. A multidisciplinary and perioperative approach involving an obstetrician, anesthesiologist, Obstetric medicine specialist and interventional radiologist is recommended.
