Research Items (102)
Objective: Pregnancies in women with Loeys Dietz Syndrome (LDS) are rare, and typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited. Design: A retrospective cohort study. Setting: 8 specialist UK centres. Sample: Pregnant women with LDS. Methods: Data was collated on cardiac, obstetric and neonatal outcomes. Main outcome measures: Maternal and perinatal outcomes in pregnancies complicated by LDS. Results: 20 pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy and 18 livebirths. In 8 women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In 4 women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery. Conclusion: Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit This article is protected by copyright. All rights reserved.
- Jan 2019
- Advanced Practice in Endocrinology Nursing
Thyroid dysfunction affects approximately 3% of pregnant women. Adequate thyroid hormone levels are important for fetal development. Normal physiological changes of pregnancy can contribute to subclinical hypothyroidism which may require treatment with thyroxine during pregnancy. Pre-existing hypothyroidism requires an increase in thyroxine dosage. Pre-existing hyperthyroidism may or may not require continued treatment with anti-thyroid medication, though these medications can rarely cause adverse fetal effects. Gestational hyperthyroidism must be distinguished from a new diagnosis of Graves’ disease in pregnancy. Gestational hyperthyroidism does not require treatment with anti-thyroid medication. Graves’ disease requires additional monitoring of mother and fetus and consideration of anti-thyroid medication. Post-partum thyroiditis is an underdiagnosed condition which can cause transient hyperthyroidism before recovery or hypothyroidism, or hypothyroidism without a hyperthyroid phase. Serial monitoring of thyroid function test is required. The vast majority of women with thyroid conditions can be managed to a successful pregnancy outcome.
Background: In response to concerns that the International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria labeled too many women with gestational diabetes mellitus (GDM) without evidence of clinical or economic benefit, NICE recommended a change in diagnostic criteria in 2015. Aim: To compare diabetes associated maternal and neonatal complications in pregnancies complicated by GDM diagnosed using IADPSG criteria only, to those with GDM diagnosed using both IADPSG and NICE 2015 criteria. GDM screening was risk factor based. Methods: This was a secondary analysis of a trial of women with GDM diagnosed by the IADPSG criteria (fasting blood glucose (BG) ≥ 5.1 mmol/L, 1 h ≥ 10.0 mmol/L and 2 h ≥ 8.5 mmol/L). Outcomes were compared for two groups: NICE + IADPSG defined as those with GDM diagnosed by both the NICE 2015 and IADPSG criteria (fasting BG ≥ 5.6 mmol/L, 2 h ≥ 8.5 mmol/L); and IADPSG-ONLY (fasting BG 5.1 mmol/L to 5.5 mmol/L, and/or 1-hour ≥10.0 mmol/L, and 2 h ≥ 8.5 mmol/L). We were not able to obtain data for women with a 2-h value between BG 7.8–8.4 mmol/L (i.e., NICE-ONLY; NICE 2015 positive and IADPSG negative). All women were treated for GDM using targets of fasting BG < 5.3 mmol/L and 1-h post prandial BG < 7.8 mmol/L respectively. Results: Of 159 women, 65 (40.9%) were NICE + IADPSG and 94 (59.1%) IADPSG-ONLY. Hypoglycaemic medication use was similar in both groups: 52.3% NICE + IADPSG, 46.8% IADPSG-ONLY, OR 1.0 (0.5–1.9). The IADPSG-ONLY group delivered later than the NICE + IADPSG group; 39.0 weeks (sd 1.4) compared to 38.2 weeks (sd 2.5), p value 0.02. Fewer caesarean sections occurred in IADPSG-ONLY group 30.9% vs. 52.3%, OR 0.4 (0.2–0.9). Birthweight, large for gestational age, and other neonatal complications were not significantly different between groups. Conclusions: Gestational diabetes-associated perinatal complications were similar in both groups. The IADPSG criteria detect women with evidence of ongoing hyperglycaemia who may benefit from treatment during pregnancy.
Hypertensive disorders during pregnancy result in substantial maternal morbidity and are a leading cause of maternal deaths worldwide. Self-monitoring of blood pressure (BP) might improve the detection and management of hypertensive disorders of pregnancy, but few data are available, including regarding appropriate thresholds. This systematic review and individual patient data analysis aimed to assess the current evidence on differences between clinic and self-monitored BP through pregnancy. MEDLINE and 10 other electronic databases were searched for articles published up to and including July 2016 using a strategy designed to capture all the literature on self-monitoring of BP during pregnancy. Investigators of included studies were contacted requesting individual patient data: self-monitored and clinic BP and demographic data. Twenty-one studies that utilized self-monitoring of BP during pregnancy were identified. Individual patient data from self-monitored and clinic readings were available from 7 plus 1 unpublished articles (8 studies; n=758) and 2 further studies published summary data. Analysis revealed a mean self-monitoring clinic difference of ≤1.2 mm Hg systolic BP throughout pregnancy although there was significant heterogeneity (difference in means, I² >80% throughout pregnancy). Although the overall population difference was small, levels of white coat hypertension were high, particularly toward the end of pregnancy. The available literature includes no evidence of a systematic difference between self and clinic readings, suggesting that appropriate treatment and diagnostic thresholds for self-monitoring during pregnancy would be equivalent to standard clinic thresholds.
Hypertension affects 1 in 10 pregnancies, often persisting postpartum, when antihypertensive requirements may vary substantially. This unmasked, randomized controlled trial evaluated the feasibility and effects on blood pressure (BP) of self-management of postpartum hypertension. Women with gestational hypertension or preeclampsia, requiring postnatal antihypertensive treatment, were randomized to self-management or usual care. Self-management entailed daily home BP monitoring and automated medication reduction via telemonitoring. Women attended 5 follow-up visits during 6 months. The primary outcome was feasibility: specifically recruitment, retention, and compliance with follow-up rates. Secondary outcomes included BP control and safety, analyzed on an intention-to-treat basis. Forty-nine percent (91/186) of those women approached were randomized (45 intervention, 46 control), and 90% (82/91) finished follow-up. The groups had similar baseline characteristics. After randomization, BP was lower in the intervention group, most markedly at 6 weeks: intervention group mean (SD), systolic 121.6 (8.7)/diastolic 80.5 (6.6) mm Hg; control group, systolic 126.6 (11.0)/diastolic 86.0 (9.7) mm Hg; adjusted differences (95% confidence interval), systolic -5.2 (-9.3 to -1.2)/diastolic -5.8 (-9.1 to -2.5) mm Hg. Diastolic BP remained significantly lower in those self-managing to 6 months: adjusted difference -4.5 (-8.1 to -0.8) mm Hg. This is the first randomized evaluation of BP self-management postpartum and indicates it would be feasible to trial this intervention in larger studies. Self-management resulted in better diastolic BP control to 6 months, even beyond medication cessation. Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02333240.
- Mar 2018
Background: Treatment of hyperglycemia in women with gestational diabetes mellitus (GDM) is associated with improved maternal and neonatal outcomes and requires intensive clinical input. This is currently achieved by hospital clinic attendance every 2 to 4 weeks with limited opportunity for intervention between these visits. Objective: We conducted a randomized controlled trial to determine whether the use of a mobile phone-based real-time blood glucose management system to manage women with GDM remotely was as effective in controlling blood glucose as standard care through clinic attendance. Methods: Women with an abnormal oral glucose tolerance test before 34 completed weeks of gestation were individually randomized to a mobile phone-based blood glucose management solution (GDm-health, the intervention) or routine clinic care. The primary outcome was change in mean blood glucose in each group from recruitment to delivery, calculated with adjustments made for number of blood glucose measurements, proportion of preprandial and postprandial readings, baseline characteristics, and length of time in the study. Results: A total of 203 women were randomized. Blood glucose data were available for 98 intervention and 85 control women. There was no significant difference in rate of change of blood glucose (-0.16 mmol/L in the intervention and -0.14 mmol/L in the control group per 28 days, P=.78). Women using the intervention had higher satisfaction with care (P=.049). Preterm birth was less common in the intervention group (5/101, 5.0% vs 13/102, 12.7%; OR 0.36, 95% CI 0.12-1.01). There were fewer cesarean deliveries compared with vaginal deliveries in the intervention group (27/101, 26.7% vs 47/102, 46.1%, P=.005). Other glycemic, maternal, and neonatal outcomes were similar in both groups. The median time from recruitment to delivery was similar (intervention: 54 days; control: 49 days; P=.23). However, there were significantly more blood glucose readings in the intervention group (mean 3.80 [SD 1.80] and mean 2.63 [SD 1.71] readings per day in the intervention and control groups, respectively; P<.001). There was no significant difference in direct health care costs between the two groups, with a mean cost difference of the intervention group compared to control of -£1044 (95% CI -£2186 to £99). There were no unexpected adverse outcomes. Conclusions: Remote blood glucocse monitoring in women with GDM is safe. We demonstrated superior data capture using GDm-health. Although glycemic control and maternal and neonatal outcomes were similar, women preferred this model of care. Further studies are required to explore whether digital health solutions can promote desired self-management lifestyle behaviors and dietetic adherence, and influence maternal and neonatal outcomes. Digital blood glucose monitoring may provide a scalable, practical method to address the growing burden of GDM around the world. Trial registration: ClinicalTrials.gov NCT01916694; https://clinicaltrials.gov/ct2/show/NCT01916694 (Archived by WebCite at http://www.webcitation.org/6y3lh2BOQ).
Appendix S1 Biomarker assays. Table S1 List of biomarker abbreviations and units Table S2 Biomarker assay information Table S3 Results of factor analysis: loadings of biomarkers on five largest factors (eigenvalues > 2) after varimax rotation showing loadings > 0.6 only and uniqueness > 0.6 Table S4 Odds ratios derived from multiple logistic regression analysis of the five factors for prediction of delivery of SGA infant in women presenting with suspected pre‐eclampsia before 35 weeks' gestation (odds ratios are for a change of 1 SD in the factor score). Factors 3 and 4 (with significant odds ratios for prediction of SGA infant < 3rd centile) were taken forward for further analysis Table S5 Odds ratios derived from multiple logistic regression analysis of five factors for prediction of delivery of SGA infant in women presenting between 35 + 0 and 36 + 6 weeks' gestation with suspected pre‐eclampsia Table S6 STROBE checklist Table S7 ROC curve areas (with 95% CI) for individual biomarkers to predict small‐for‐gestational age (SGA) < 3rd and < 10th customized birth‐weight centiles in women presenting with suspected pre‐eclampsia before 35 weeks' gestation Table S8 Individual median biomarker concentrations (quartiles) in women presenting before 35 weeks' gestation with suspected pre‐eclampsia Table S9 Predictive performance of individual indicators and their combinations, to predict delivery of small‐for‐gestational age (SGA) < 10th customized birth‐weight centile in 129 women presenting at 20 + 0 to 34 + 6 weeks' gestation with suspected pre‐eclampsia, who underwent ultrasound examination within 14 days of enrolment Table S10 Predictive performance of individual indicators and their combinations, to predict delivery of small‐for‐gestational age (SGA) < 3rd customized birth‐weight centile in 109 women presenting at 20 + 0 to 34 + 6 weeks' gestation with suspected pre‐eclampsia, who underwent ultrasound examination within 14 days of enrolment, excluding those with known abnormal scan findings on day of enrolment Table S11 Test performance statistics for individual indicators and their combinations to predict adverse perinatal outcome in 109 women presenting before 35 weeks' gestation with suspected pre‐eclampsia, who underwent ultrasound examination within 14 days of enrolment, excluding those with known abnormal scan findings on day of enrolment Table S12 Characteristics of 123 women presenting between 35 + 0 and 36 + 6 weeks' gestation with suspected pre‐eclampsia (PE), according to subsequent birth weight of infant Table S13 Delivery characteristics and maternal and neonatal outcome of 123 women presenting between 35 + 0 and 36 + 6 weeks' gestation with suspected pre‐eclampsia (PE), according to subsequent birth weight of infant Table S14 Individual biomarker areas under receiver–operating characteristics curves (AUCs) when sampled between 35 + 0 and 36 + 6 weeks' gestation Table S15 Predictive performance of individual biomarkers and combinations (derived from logistic regression) for prediction of small‐for‐gestational age (SGA) < 3rd centile and < 10th centile in 123 women presenting between 35 + 0 and 36 + 6 weeks' gestation with suspected pre‐eclampsia Table S16 Predictive performance of individual indicators and their combinations, to predict small‐for‐gestational age (SGA) < 3rd customized birth‐weight centile in 53 women presenting between 35 + 0 and 36 + 6 weeks' gestation with suspected pre‐eclampsia, who underwent ultrasound examination within 14 days of enrolment Table S17 Predictive performance of individual indicators and their combinations, to predict small‐for‐gestational age (SGA) < 10th customized birth‐weight centile in 53 women presenting between 35 + 0 and 36 + 6 weeks' gestation with suspected pre‐eclampsia, who underwent ultrasound examination within 14 days of enrolment Table S18 Predictive performance of individual indicators and their combinations, to predict adverse perinatal outcome in 53 women presenting between 35 + 0 and 36 + 6 weeks' gestation with suspected pre‐eclampsia, who underwent ultrasound examination within 14 days of enrolment
- Jan 2018
Background Inflammatory bowel disease (IBD) commonly affects women during their childbearing years. Published data suggest that observed low fertility rates in IBD are due to voluntary childlessness and quiescent IBD does not confer decreased fertility. Active IBD at conception is reportedly associated with higher rates of preterm birth, low birth weight, and caesarean section (C-section). Reproductive choices and outcomes relating to fertility and pregnancy remain important concerns in IBD populations. The Oxford University Hospitals (OUH) NHS Foundation Trust is a tertiary centre with >8500 deliveries per year and >3500 IBD patients. All pregnant IBD patients are referred to the Silver Star obstetrics medical team. The Oxford IBD service aims to impart accurate pregnancy information and provides a comprehensive information booklet. We present our recent reproductive outcomes in IBD. We compared IBD conception, termination rates, and pregnancy outcomes with local and national data, and in the context of IBD phenotype. Methods Women aged 15–55 years with IBD from January 2012 to May 2016 were identified via the IBD database. ICD codes identified miscarriage, ectopic pregnancy, termination, delivery mode, and outcomes. Comparative analysis was performed. Results A total of 1127 women aged 15–55 years with IBD are cared for at OUH. The total cohort is 240 women who had 323 pregnancies. IBD pregnant women demonstrate reduced anti-TNF use and surgery, and are more frequently on no medication than age- and sex-matched IBD. Conception rates (43.1 vs. 76.1 per 1000 women) markedly differ from a healthy population. Our IBD patients exhibit no difference in gestation, birthweight or the majority of pregnancy-related outcomes. Cholestasis of pregnancy rates are markedly different (6.9% vs. 0.32–0.58%) despite no association with PSC. Women with IBD are more likely to deliver by C-section (41% vs. 23%). Conclusions Our IBD population has comparative pregnancy outcomes to healthy controls, the exceptions being C-section rates and cholestasis of pregnancy. Conception rates in our IBD population remain low compared with healthy controls.
Background Hypertensive disorders in pregnancy are a leading cause of maternal and fetal morbidity worldwide. Raised blood pressure (BP) affects 10% of pregnancies worldwide, of which almost half develop pre-eclampsia. The proportion of pregnant women who have risk factors for pre-eclampsia (such as pre-existing hypertension, obesity and advanced maternal age) is increasing. Pre-eclampsia can manifest itself before women experience symptoms and can develop between antenatal visits. Incentives to improve early detection of gestational hypertensive disorders are therefore strong and self-monitoring of blood pressure (SMBP) in pregnancy might be one means to achieve this, whilst improving women’s involvement in antenatal care. The Blood Pressure Self-Monitoring in Pregnancy (BuMP) study aimed to evaluate the feasibility and acceptability of SMBP in pregnancy. Methods To understand women’s experiences of SMBP during pregnancy, we undertook a qualitative study embedded within the BuMP observational feasibility study. Women who were at higher risk of developing hypertension and/or pre-eclampsia were invited to take part in a study using SMBP and also invited to take part in an interview. Semi-structured interviews were conducted at the women’s homes in Oxfordshire and Birmingham with women who were self-monitoring their BP as part of the BuMP feasibility study in 2014. Interviews were conducted by a qualitative researcher and transcribed verbatim. A framework approach was used for analysis. ResultsFifteen women agreed to be interviewed. Respondents reported general willingness to engage with monitoring their own BP, feeling that it could reduce anxiety around their health during pregnancy, particularly if they had previous experience of raised BP or pre-eclampsia. They felt able to incorporate self-monitoring into their weekly routines, although this was harder post-partum. Self-monitoring of BP made them more aware of the risks of hypertension and pre-eclampsia in pregnancy. Feelings of reassurance and empowerment were commonly reported by the women in our sample. ConclusionsSMBP in pregnancy was both acceptable and feasible to women in this small pilot study.
Background Raised blood pressure (BP) affects approximately 10% of pregnancies worldwide, and a high proportion of affected women develop pre-eclampsia. This study aimed to evaluate the feasibility of self-monitoring of BP in pregnancy in women at higher risk of pre-eclampsia. Methods This prospective cohort study of self-monitoring BP in pregnancy was carried out in two hospital trusts in Birmingham and Oxford and thirteen primary care practices in Oxfordshire. Eligible women were those defined by the UK National Institute for Health and Care Excellence (NICE) guidelines as at higher risk of pre-eclampsia. A total of 201 participants were recruited between 12 and 16 weeks of pregnancy and were asked to take two BP readings twice daily three times a week through their pregnancy. Primary outcomes were recruitment, retention and persistence of self-monitoring. Study recruitment and retention were analysed with descriptive statistics. Survival analysis was used to evaluate the persistence of self-monitoring and the performance of self-monitoring in the early detection of gestational hypertension, compared to clinic BP monitoring. Secondary outcomes were the mean clinic and self-monitored BP readings and the performance of self-monitoring in the detection of gestational hypertension and pre-eclampsia compared to clinic BP. ResultsOf 201 women recruited, 161 (80%) remained in the study at 36 weeks or to the end of their pregnancy, 162 (81%) provided any home readings suitable for analysis, 148 (74%) continued to self-monitor at 20 weeks and 107 (66%) at 36 weeks. Self-monitored readings were similar in value to contemporaneous matched clinic readings for both systolic and diastolic BP. Of the 23 who developed gestational hypertension or pre-eclampsia and self-monitored, 9 (39%) had a raised home BP prior to a raised clinic BP. Conclusions Self-monitoring of BP in pregnancy is feasible and has potential to be useful in the early detection of gestational hypertensive disorders but maintaining self-monitoring throughout pregnancy requires support and probably enhanced training.
- Nov 2017
Objective: To investigate feasibility and acceptability of self-testing for proteinuria during pregnancy. Study design: Mixed methods approach which included: an accuracy study where pregnant women (n = 100) and healthcare professionals (n = 96) tested seven synthetic protein samples and completed a questionnaire, a feasibility study where pregnant women who were self-monitoring their blood pressure were asked to self-test for proteinuria (n = 30), and an online questionnaire about women's experiences of self-testing (n = 200). Main outcome measures: Sensitivity and specificity of testing and questionnaire results. Results: There were no significant differences in the accuracy of synthetic sample testing by pregnant women (sensitivity 0.81 (95% confidence intervals (CI) 0.78-0.85), specificity 0.93 (95% CI 0.91-0.95)) and healthcare professionals: (sensitivity 0.83 (95% CI 0.79-0.86), specificity 0.92 (95% CI 0.90-0.94)). Automated readers had significantly better sensitivity (0.94 (0.91-0.97) (p ≤ .001 in each case), but worse specificity 0.78 (0.69-0.85). Similar results were gained using self-tested urine samples compared to staff-testing using a reference standard of laboratory urine protein-creatinine ratio (uPCR). Women who completed the online survey with experience of self-testing (n = 39, 20%) generally found it easy, and with support from healthcare professionals felt it improved involvement in their care and reduced anxiety. Conclusions: Self-testing for proteinuria by pregnant women had similar accuracy to healthcare professional testing and was acceptable to both groups. Self-testing of urine combined with self-monitoring of blood pressure could provide a useful adjunct to clinic-based surveillance for the detection of pre-eclampsia. Such novel strategies warrant further research.
Objectives Hypertensive disorders of pregnancy (HDP) affect one in ten pregnancies and often persist postpartum when complications can occur. We aimed to determine the effectiveness and safety of pharmacological interventions, other interventions and different care models for postpartum hypertension management. Design A systematic review was undertaken. Nine electronic databases, including Medline, were searched from inception to 16 March 2017. After duplicate removal, 4561 records were screened. Two authors independently selected studies, extracted study characteristics and data, and assessed methodological quality. Setting Randomised controlled trials, case–control studies and cohort studies from any country and healthcare setting. Participants Postnatal women with HDP. Interventions Therapeutic intervention for management of hypertension, compared with another intervention, placebo or no intervention. Primary and secondary outcome measures Outcome data were collected for maternal mortality and severe morbidity; systolic, diastolic and mean arterial blood pressure (BP) control; and safety data. Secondary outcome data collected included the length of postnatal hospital stay and laboratory values. Results 39 studies were included (n=2901). Results were heterogeneous in terms of intervention, comparison and outcome requiring a narrative approach. There were insufficient data to recommend any single pharmacological intervention. 18 studies reported calcium-channel blockers, vasodilators and beta-blockers lowered BP postpartum. 12 of these reported safety data. Limited data existed regarding management in the weeks following hospital discharge. Neither loop diuretics (three studies) nor corticosteroids (one study) produced clinical benefit. Uterine curettage significantly reduced BP over the first 48 hours postpartum (range 6–13 mm Hg) compared with standard care (eight studies), with safety data only reported by four of eight studies. Conclusion There was insufficient evidence to recommend a particular BP threshold, agent or model of care, but three classes of antihypertensive appeared variably effective. Further comparative research, including robust safety data, is required. Curettage reduced BP, but without adequate reporting of harms, so it cannot currently be recommended.
Introduction Successive confidential enquiries into maternal deaths in the UK have identified an urgent need to develop a national early warning score (EWS) specifically for pregnant or recently pregnant women to aid more timely recognition, referral and treatment of women who are developing life-threatening complications in pregnancy or the puerperium. Although many local EWS are in use in obstetrics, most have been developed heuristically. No current obstetric EWS has defined the thresholds at which an alert should be triggered using evidence-based normal ranges, nor do they reflect the changing physiology that occurs with gestation during pregnancy. Methods and analysis An observational cohort study involving 1000 participants across three UK sites in Oxford, London and Newcastle. Pregnant women will be recruited at approximately 14 weeks’ gestation and have their vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation and temperature) measured at 4 to 6-week intervals during pregnancy. Vital signs recorded during labour and delivery will be extracted from hospital records. After delivery, participants will measure and record their own vital signs daily for 2 weeks. During the antenatal and postnatal periods, vital signs will be recorded on an Android tablet computer through a custom software application and transferred via mobile internet connection to a secure database. The data collected will be used to define reference ranges of vital signs across normal pregnancy, labour and the immediate postnatal period. This will inform the design of an evidence-based obstetric EWS. Ethics and dissemination The study has been approved by the NRES committee South East Coast–Brighton and Sussex (14/LO/1312) and is registered with the ISRCTN (10838017). All participants will provide written informed consent and can withdraw from the study at any point. All data collected will be managed anonymously. The findings will be disseminated in international peer-reviewed journals and through research conferences.
Epilepsy is the most common serious neurological problem encountered in pregnancy; however, women with epilepsy are often not referred to high-risk pregnancy services. The 2015 Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) report on maternal mortality highlights that the care of pregnant women with epilepsy requires urgent improvement. The two most recently available guidelines (Scottish Intercollegiate Guidelines Network and Royal College of Obstetricians and Gynaecologists guidelines) require comparative critical appraisal. Collaboration between general practitioners, specialist epilepsy nurses/midwives, obstetricians, obstetric physicians, neurologists and anaesthetists is vital to ensure optimal standardised management. To understand the role of pre-conception counselling: to include advice on seizure control, anti-epileptic drugs (AEDs) and pre-conception folic acid. To understand the risk factors associated with poor outcomes in pregnant women with epilepsy. To understand the risks associated with specific types of AEDs: mono- and polytherapy. To understand the issues regarding the titration of AEDs during pregnancy, postnatal and breastfeeding periods. To understand the importance of a multidisciplinary antenatal, intrapartum and postnatal schedule of care and special considerations. When should we advise women to avoid pregnancy? When, how and by whom should AEDs be modified? Are women with epilepsy aware of the risk of sudden unexpected death in epilepsy in pregnancy?
- Jul 2017
Question We performed an initial evaluation of a novel self-management intervention for the titration of antihypertensive therapy by hypertensive women following delivery aiming to assess both feasibility and effect on blood pressure. Methods Postnatal women, with gestational hypertension or pre-eclampsia requiring antihypertensive treatment, were randomised to self-management or usual care and attended five follow-up visits over six months. Self-management entailed daily self-monitoring of blood pressure (BP) and measurement submission via a mobile phone-based telemonitoring system. The primary outcome was feasibility. A repeated measures mixed-effects regression model was used to analyse differences in BP during follow-up. Results 91 of 188 (48%) women approached were randomised (45 intervention, 46 control), with 9/91 (10%) withdrawals. Amongst the 82 complete cases, 403/410 (98%) follow-up visits were completed. The groups had similar baseline characteristics. BP at follow-up tended to be lower in those self-managing: This was most marked at 6 weeks [adjusted mean differences, self-management lower: systolic BP −5.2 mmHg (−9.3 to −1.2); diastolic BP −5.8 mmHg (−9.1 to −2.5)] and the difference in diastolic readings persisted to six months [−4.5 mmHg (−8.1 to −0.8)] despite all but one woman completing therapy. Conclusions This first randomised controlled evaluation of BP self-management postpartum showed the intervention was feasible and secondary outcome measures indicate that self-management may achieve better BP control; These results support evaluation on a larger scale.
- May 2017
Aim: To determine the utilisation of computed tomography pulmonary angiography (CTPA) and lung scintigraphy in the UK, and to assess their diagnostic qualities in the investigation of suspected pulmonary embolism (PE) in pregnancy. Materials and methods: Data were collected via electronic questionnaire in the UK from 24 sites. Data on the choice of imaging technique, radiation dose, technical adequacy, weeks' gestation, presenting symptoms, and further management of patients with indeterminate imaging were collected. Results: The sample represented a population of 15.5 million and showed wide variation in the probability of investigation of suspected PE with rates per live birth of 0.06-2.2%. Nine hundred and ninety-one patients were imaged and there were 48 positive scans, an incidence of 0.038%. Of the 269 CTPAs performed, 5.9% were positive, 8.9% were technically inadequate. Of the 769 scintigraphy scans performed, 3.8% were positive and 9.1% were indeterminate; 63% of positive scans were in the third trimester. Most inadequate/indeterminate scans were in the third trimester. The calculated typical radiation dose to the breast and fetus from CTPA ranged from 14 to 2 mGy and 0.02 to 0.002mGy, respectively, and approximately 0.28 and 0.2 mGy, respectively, from scintigraphy. Conclusion: The incidence of PE in this population was extremely low and the number of indeterminate or inadequate scans was comparable. This suggests choice of imaging should be made based upon availability and radiation exposure.
- Apr 2017
Objective: To evaluate the test performance of 47 biomarkers and ultrasound parameters to predict subsequent delivery of an SGA infant and adverse perinatal outcome in women presenting with suspected preeclampsia. Methods: In a prospective, multicentre observational study, 47 biomarkers and ultrasound parameters were measured in 397 women presenting with suspected preterm preeclampsia, with the objective of evaluating them as predictors of subsequent delivery of an SGA infant and adverse perinatal outcome. Factor analysis and stepwise logistic regression were performed in two pre-specified groups. Results: In 274 women presenting at 20(+0) to 34(+6) weeks' gestation (Group 1), 96 (35%) delivered an SGA infant <3(rd) customised birthweight centile (SGA-3). For prediction of SGA-3, low maternal Placental Growth Factor (PlGF) concentrations had a sensitivity of 93% (95%CI 84% to 98%) and negative predictive value (NPV) of 90% (95%CI 76% to 97%) compared to a sensitivity of 71% (95%CI 58% to 82%) and a NPV of 79% (95%CI 68% to 87%) for ultrasound parameters (estimated fetal weight or abdominal circumference <10(th) centile). No individual biomarker evaluated had superior performance to PlGF and combinations added only small increments to test performance. Similar results were found in 123 women presenting between 35(+0) to 36(+6) weeks' gestation (Group 2). Conclusions: In women presenting with suspected preterm preeclampsia, measurement of PlGF offers a useful adjunct for identifying those at high risk of delivering an SGA infant, allowing appropriate surveillance and timely intervention.
- Feb 2017
Breathlessness in pregnancy is a very common symptom. We discuss in this review, the physiological changes to the respiratory system in pregnancy and the commonly seen respiratory ailments like asthma, pneumonia and tuberculosis. Treatments for most conditions are similar to those administered to non-pregnant women. However, conditions may sometimes deteriorate rapidly in pregnancy and hence prompt recognition and treatment is crucial. Investigations should be appropriately used and should not be withheld in pregnancy if indicated. The effect of each condition on pregnancy, of pregnancy on the condition, treatments that can be safely used, management in pregnancy and in labour, and effects on the fetus and the neonate are discussed.
Background Diabetes in pregnancy is a global problem. Technological innovations present exciting opportunities for novel approaches to improve clinical care delivery for gestational and other forms of diabetes in pregnancy. Objective To perform an updated and comprehensive systematic review and meta-analysis of the literature to determine whether telemedicine solutions offer any advantages compared with the standard care for women with diabetes in pregnancy. Methods The review was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Randomized controlled trials (RCT) in women with diabetes in pregnancy that compared telemedicine blood glucose monitoring with the standard care were identified. Searches were performed in SCOPUS and PubMed, limited to English language publications between January 2000 and January 2016. Trials that met the eligibility criteria were scored for risk of bias using the Cochrane Collaborations Risk of Bias Tool. A meta-analysis was performed using Review Manager software version 5.3 (Nordic Cochrane Centre, Cochrane Collaboration). Results A total of 7 trials were identified. Meta-analysis demonstrated a modest but statistically significant improvement in HbA1c associated with the use of a telemedicine technology. The mean HbA1c of women using telemedicine was 5.33% (SD 0.70) compared with 5.45% (SD 0.58) in the standard care group, representing a mean difference of −0.12% (95% CI −0.23% to −0.02%). When this comparison was limited to women with gestational diabetes mellitus (GDM) only, the mean HbA1c of women using telemedicine was 5.22% (SD 0.70) compared with 5.37% (SD 0.61) in the standard care group, mean difference −0.14% (95% CI −0.25% to −0.04%). There were no differences in other maternal and neonatal outcomes reported. Conclusions There is currently insufficient evidence that telemedicine technology is superior to standard care for women with diabetes in pregnancy; however, there was no evidence of harm. No trials were identified that assessed patient satisfaction or cost of care delivery, and it may be in these areas where these technologies may be found most valuable.
Objective To model the resource implications of placental growth factor (PlGF) testing in women with suspected pre-eclampsia prior to 35 weeks’ gestation as part of a management algorithm, compared with current practice. Methods Data on resource use from 132 women with suspected pre-eclampsia prior to 35 weeks’ gestation, enrolled in a prospective observational cohort study evaluating PlGF measurement within antenatal assessment units within two UK consultant-led maternity units was extracted by case note review. A decision analytic model was developed using these data to establish the budget impact of managing women with suspected pre-eclampsia for two weeks from the date of PlGF testing, using a clinical management algorithm and reference cost tariffs. The main outcome measures of resource use (numbers of outpatient appointments, ultrasound investigations and hospital admissions) were correlated to final diagnosis and used to calculate comparative management regimes. Results The mean cost saving associated with the PlGF test (in the PlGF plus management arm) was £35,087 (95% CI -£33,181 to -£36,992) per 1,000 women. This equated to a saving of £582 (95% CI -552 to -£613) per woman tested. In 94% of iterations, PlGF testing was associated with cost saving compared to current practice. Conclusions This analysis suggests PlGF used as part of a clinical management algorithm in women presenting with suspected pre-eclampsia prior to 35 weeks’ gestation could provide cost savings by reducing unnecessary resource use. Introduction of PlGF testing could be used to direct appropriate resource allocation and overall would be cost saving.
Aims: Turners syndrome (TS) is associated with bicuspid aortic valve (BAV), ascending aortic dilatation (AD), aortic coarctation, and hypertension. Pregnancy in TS is associated with increased risk of aortic dissection (2%), gestational hypertension, pre-eclampsia and a 2% risk of maternal mortality. This retrospective study aimed to assess the effectiveness of a multidisciplinary team (MDT) comprising endocrinologist, cardiologist and maternal medicine obstetrician providing risk-assessment, pre-conception counselling and close follow-up, on safety and improving pregnancy outcomes in TS. Methods: From a total of 104 women attending our dedicated TS clinic, we identified 23 spontaneous pregnancies (SP, 3/23 45XO) and six pregnancies with oocyte donation (OD). Clinical data, blood pressure measurements and aortic dimensions (indexed for body surface area) were analysed. Echocardiography, cardiac magnetic resonance (CMR), pre-conception counselling and risk-assessment were performed. Surveillance echocardiography and cardiologist review were performed each trimester and monthly if AD was detected. Echocardiography and CMR were repeated six months post-delivery. Results: Total 26 successful pregnancies (3 following OD), maternal age 28±7 years. Pre-conception cardiovascular risk-assessment identified hypertension in 6 women, BAV in 7 (1 with moderate aortic stenosis), AD (>2.0 cm/m²) in 4, coarctation repair and correction of congenital heart disease in 1 and thoracic aortic graft in 1. Seven women developed mild aortic dilatation (1±2 mm). Aortic dimensions increased slightly after pregnancy: aortic root 1.79±0.32 cm/m² (1.84±0.37 cm/m²; P=0.07) and ascending aorta 1.69±0.40 cm/m² (1.71±0.41 cm/m²; P=0.83). Complications were low: gestational hypertension (n=1), diabetes (n=1), aortic dissection (n=0), pre-eclampsia (n=0), and no mortalities. Delivery was at 39±1 weeks, birth weight 3.1±0.6 kg, with 81% caesarian deliveries, n=1 child with TS and n=1 stillbirth. Conclusions: Pre-conception counselling including risk-assessment by a dedicated MDT, along with close surveillance by a cardiologist with serial echocardiography, ensures low complications and excellent maternal and fetal outcomes, suggesting a more optimistic approach to pregnancy is appropriate in TS women.
Aims: Oocyte donation (OD) is increasingly utilised in women with Turners syndrome (TS). However, guidelines state TS a relative contraindication for pregnancy, due to increased risk of aortic dissection (AD 2%) and maternal mortality (2%). Recent data on OD-related morbidity and mortality in TS has raised further concern. We aimed to analyse cardiovascular risk profiles of TS women undergoing OD and those with spontaneous pregnancy (SP), and determine outcomes in a setting of rigorous peri-pregnancy monitoring by a multidisciplinary team. Methods: Of 104 women seen at a dedicated multidisciplinary TS clinic, 14 had SP (3/14 45XO) and 6 OD (3/6 45XO). Cardiovascular risk factors, aortic sinuses (AS) and ascending aorta (AA) measurements, maternal and fetal morbidity and mortality were analysed. Results: There were 26 successful pregnancies (3 from OD). Baseline features in SP vs OD were: age at pregnancy 24±6 years vs 35±4 years (P<0.001); hypertension 15% vs 66% (P<0.05); bicuspid aortic valve 23% vs 50% (P<0.05); AS 1.69±0.17 cm/m² vs 2.02±0.41 cm/m² (P<0.05); AA 1.50±0.22 vs 2.04±0.44 cm/m² (P<0.01). There were no differences in BMI 27.6±3.1 vs 29.0±6.4, comorbidities 21% vs 66%, or previous aortic surgery 8% vs 17%. Post-pregnancy aortic dimensions were: AS 1.70±0.23 (SP) vs 2.16±0.48 (OD, P<0.05) and AA 1.58±0.22 vs 2.10±0.61 (P<0.05), but Δ increase was not significant (AS: Δ 0.07±0.14 vs 0.10±0.16; AA: Δ 0.03±0.11 vs −0.02±0.27, P=ns). There were no cases of AD, pre-eclampsia or maternal mortalities. Delivery was at 39±1 week vs 38±0 weeks (P=ns), with caesarean deliveries in 77% vs 100% (P=ns) and one still-birth (SP). Conclusions: Women with TS undergoing OD were older and had more cardiovascular risk factors. However, pregnancy outcomes were comparable to the SP group with minimal maternal complications and excellent survival. Rigorous risk-assessment, peri-pregnancy monitoring and follow-up by a specialist multidisciplinary team can result in safe and successful outcomes in these women.
The syndrome of haemolysis, elevated liver enzymes and low platelets is a rare condition specific to pregnancy, affecting approximately 5–20% of all pre-eclamptic pregnancies. Described here is a woman in her first pregnancy, who experienced an intrauterine death following a significant hepatic haematoma and capsular rupture, in the absence of classical clinical features suggestive of pre-eclampsia. The events that followed suggested haemolysis, elevated liver enzymes and low platelets syndrome as the likely diagnosis. The patient’s clinical course highlights the difficulties that may be encountered when making decisions about pregnant women with complicated medical and obstetric issues.
The physiological and haemodynamic changes that occur in pregnancy and the postpartum period increase the risk of aortic dissection. Loeys-Dietz syndrome results from mutations in the genes encoding components of the TGF-β signalling pathway; aortic pathology is of particular concern in this condition but other vascular abnormalities can also be present. Significant maternal morbidity and mortality has been described in patients with Loeys-Dietz syndrome, but successful and uncomplicated pregnancies are still possible. Nevertheless, all patients with this condition should, at present, be treated as very high risk in pregnancy and the postpartum period, until reliable risk prediction tools become available. This review summarises the recent advances in the understanding of the pathophysiology of this condition, and the management strategies currently advocated.
- Aug 2016
Hypertensive disorders of pregnancy affect approximately one in ten pregnancies and often persist postpartum. Their postnatal course can be unpredictable and complications may occur, hence control remains important but is informed by little evidence. Clinicians from UK primary and secondary healthcare were invited to complete a survey regarding antihypertensive adjustment postpartum. The response rate was 101/390 (26%). Labetalol was the commonest antihypertensive used. Most participants reported following national guidelines when reducing, although not increasing, antihypertensive medications. The results suggest an unwarranted and unjustifiable variation in management – underlining the evidence gap – additional research is needed to inform the standardisation of care.
- Jul 2016
Objective: To evaluate 47 biomarkers (selected from the current medical literature), in isolation or in combination with placental growth factor (PlGF), to determine the need for delivery within 14 days, in women presenting with suspected preterm preeclampsia. Methods: In a prospective, multicenter observational study, 47 biomarkers were measured in 423 women presenting with suspected preterm preeclampsia (in two prespecified groups: group 1 at less than 35 weeks of gestation and group 2 presenting between 35 0/7 and 36 6/7 weeks of gestation) to evaluate their ability to determine the primary endpoint: preeclampsia requiring delivery within 14 days. Using factor analysis and stepwise logistic regression, we sought one or more additional biomarkers for optimal determination of the primary endpoint. Results: In women presenting at less than 35 weeks of gestation (n=286), the best performing combination of PlGF, podocalyxin, endoglin, procalcitonin (receiver operating curve [ROC] area 0.90, 95% confidence interval [CI] 0.86-0.93) was not statistically better than PlGF alone (ROC 0.87, 95% CI 0.83-0.92; P=.43) for preeclampsia requiring delivery within 14 days. Two other single markers had test performance that was not significantly different to PlGF (soluble fms-like tyrosine kinase-1 [sFlt-1] ROC 0.83, 95% CI 0.78-0.88; endoglin ROC 0.83, 95% CI 0.79-0.88). Similar findings were found in women presenting between 35 0/7 and 36 6/7 weeks of gestation (n=137): ROC for PlGF alone 0.75 (95% CI 0.67-0.83); ROC for PlGF, cystatin, pregnancy-associated plasma protein A in combination 0.81 (95% CI 0.74-0.88; P=.40). Conclusion: This study supports the growing body of evidence that a single angiogenesis-related biomarker (PlGF, sFlt-1, or endoglin) alone represents a useful diagnostic test for women presenting with suspected preterm preeclampsia.
- May 2016
Aims: Women with Turners syndrome (TS) are increasingly undertaking pregnancies, either via natural conception (mosaic TS) or assisted conception (AC). Increased TS pregnancies have led to reports suggesting high risk of pregnancy associated aortic dissection (AOD) 2%, and maternal mortality 2% due to underlying aortic valve abnormalities and aortopathies. However, the literature is limited to small case series. We report our practice providing risk-assessment and combined specialist TS endocrinology, cardiology and obstetrics services, resulting in low maternal and fetal complications. Methods: Data were retrospectively analysed for patients with spontaneous pregnancy or AC with multidisciplinary risk-assessment and care during pregnancy and peurperium, and follow-up in a specialist TS clinic between 2009 and 2016. Results: Of 87 TS patients, thirteen (15%) had spontaneous pregnancies and six (7%) had AC with three successful pregnancies. Pre-conception risk-assessment and counselling were conducted by a multidisciplinary team comprising TS endocrinologist, obstetrician and cardiologist with echocardiography ± cardiac magnetic resonance imaging. Five patients had pre-existing cardiovascular disease (bicuspid aortic valve [n=5]; dilated aortic root or ascending aorta [n=4]; moderate aortic stenosis [n=1]; hypertension [n=3]; surgery for dilated ascending aorta [n=1]; and for complex congenital heart disease including coarctation [n=1]). During pregnancy, patients underwent regular review by a TS endocrinologist, cardiologist with echocardiography and obstetrician in a high-risk maternity clinic. Fetal cardiologist assessment occurred at 20 weeks gestation. Maternal echocardiography was performed post-partum. There were 16 successful live-births (n=13 spontaneous pregnancies, n=3 AC). One patient developed gestational hypertension which responded to medical therapy. One patient developed mild progression of aortic root dilatation post-partum. There were no cases of moderate or severe aortic dilatation, AOD, pre-eclampsia, maternal deaths or fetal cardiac disease. Conclusions: Pre-pregnancy risk-assessment and close multidisciplinary care by endocrinology, cardiology and obstetrics services during pregnancy and the peurperium ensures low maternal complications and excellent survival in TS.
Introduction The prevalence of gestational diabetes mellitus (GDM) is rising in the UK. Good glycaemic control improves maternal and neonatal outcomes. Frequent clinical review of patients with GDM by healthcare professionals is required owing to the rapidly changing physiology of pregnancy and its unpredictable course. Novel technologies that allow home blood glucose (BG) monitoring with results transmitted in real time to a healthcare professional have the potential to deliver good-quality healthcare to women more conveniently and at a lower cost to the patient and the healthcare provider compared to the conventional face-to-face or telephone-based consultation. We have developed an integrated GDm-health management system and aim to test the impact of using this system on maternal glycaemic control, costs, patient satisfaction and maternal and neonatal outcomes compared to standard clinic care in a single large publicly funded (National Health Service (NHS)) maternity unit. Methods and analysis Women with confirmed gestational diabetes in a current pregnancy are individually randomised to either the GDm-health system and half the normal clinic visits or normal clinic care. Primary outcome is mean BG in each group from recruitment to delivery calculated, with adjustments made for number of BG measurements, proportion of preprandial and postprandial readings and length of time in study, and compared between the groups. The secondary objective will be to compare the two groups for compliance to the allocated BG monitoring regime, maternal and neonatal outcomes, glycaemic control using glycated haemoglobin (HbA1c) and other BG metrics, and patient attitudes to care assessed using a questionnaire and resource use. Ethics and dissemination Thresholds for treatment, dietary advice and clinical management are the same in both groups. The results of the study will be published in a peer-reviewed journal and disseminated electronically and in print. Trial registration number NCT01916694; Pre-results.
- Mar 2016
Vaccinations are a cost-effective means of preventing disease. They may be recommended in pregnancy for maternal benefit or for prevention of intrauterine infection of the fetus. Increasingly, it is recognised that vaccination in pregnancy can provide protection through passive immunity for the newborn infant. The MBRRACE-UK 2014 report demonstrated that one in eleven maternal mortalities between 2009 and 2012 were a direct result of influenza infection. More than half of these deaths could have been prevented by vaccination in pregnancy. Theoretical concerns regarding adverse effects of vaccination on the fetus and lack of efficacy have, in general, not been confirmed by clinical evidence. Nevertheless live attenuated vaccines remain contraindicated due to risk of fetal infection. As with any clinical decision, advice on antenatal vaccination should be based on the balance of risks and benefits to mother and fetus. This review aims to guide such decisions by discussing the issues surrounding commonly used vaccines and presenting current UK guidelines.
Introduction Vital signs (blood pressure, heart rate, temperature, oxygen saturation and respiratory rate) are thought to undergo changes during and immediately after pregnancy. However, these physiological changes are not taken into account in the normal ranges, which themselves are not evidence-based, used in routine and acute care monitoring. We aim to synthesise the existing evidence base for changes in vital signs during pregnancy, in order to derive new centile charts for each stage of pregnancy and the immediate postpartum period. Methods and analysis We will search the MEDLINE, EMBASE and CINAHL databases from their inception to April 2015 for vital signs from pregnant, intrapartum or postpartum women who were recruited as ‘healthy’. Assessment of bias will be conducted using a predefined set of independently agreed methodological criteria, which assigns an overall quality score to each study. We will record whether the vital sign measurements were made with measurement devices validated for use in pregnancy and in a standard posture. We will use regression methods to construct centile charts of vital signs across pregnancy and the immediate postpartum period for each vital sign. We will compare existing reference ranges to those derived from our centile charts. Dissemination The systematic review will be published in a peer-reviewed journal and disseminated electronically and in print. PROSPERO reference CRD42014009673.
- Jan 2016
The authors discuss commencing biologics in pregnancy and the potential side effects. Infection is a particular risk, which may be atypical or present atypically. While there is no evidence of teratogenicity, these drugs cross the placenta and neonatal cord drug levels may exceed those of maternal drug levels. If possible, anti-tumour necrosis factor (TNF) agents should be discontinued midtrimester but the gestation to which each drug can be used is slightly different. Neonates exposed in utero to anti-TNF agents beyond the recommended gestation should not be given live attenuated vaccines for the first 6 months of life and any infections promptly treated. Data are lacking on the long-term effects of biologics on children exposed in utero. However, the benefits of controlling active autoimmune disease in the mother often outweigh the small risk to the exposed infants. To know the biologics most commonly used in pregnancy. To understand the literature regarding safety of the common biologics in pregnancy. To be able to counsel a woman taking a biologic about the potential benefits and risks of taking it at different gestations. To be able to counsel a woman receiving biologics in pregnancy about vaccinations for her baby after birth. Biologic agents are relatively new drugs that are being increasingly used in young women because of their perceived ‘fertility sparing’ benefits despite a lack of high quality evidence. Most women who have been prescribed biologics are often refractory to other treatments, and therefore these agents are required for disease control. The decision to continue or discontinue these drugs in pregnancy, especially late pregnancy, is particularly contentious. The long-term effect of biologics on infants exposed in utero is not known and the decision to use these drugs has to be balanced against the risk of severe maternal flares.
Pregnancy is an insulin resistant state. Hyperglycaemia and gestational diabetes mellitus are well-recognised complications even in women without existing metabolic syndrome or obesity. Pregnant women also appear to be more vulnerable to ketoacidosis, particularly after short periods of reduced oral intake in the third trimester, and may present with very severe starvation ketoacidosis, prompting emergent delivery. We present a case of a woman with a background of depression and psychotic episodes. Olanzapine had been commenced after a psychotic episode at 20 weeks’ gestation. Gestational diabetes mellitus was diagnosed at 28 weeks, and she was then admitted at 31 weeks with severe euglycaemic ketoacidosis following a short period of vomiting. She underwent caesarean section when the metabolic disturbances did not resolve with medical treatment. We believe atypical antipsychotic therapy contributed to the profound insulin resistance seen here, and that obstetricians, physicians and psychiatrists must be aware of the risks conferred by these agents in pregnancy.
Introduction: Pre-eclampsia (raised blood pressure and proteinuria) complicates 2% to 8% of pregnancies, and increases morbidity and mortality in the mother and child. Pre-eclampsia is more common in older women, women with a high body mass index, and women with multiple pregnancy. Pre-eclampsia risk is also increased in women with underlying medical conditions, particularly conditions associated with microvascular disease. Methods and outcomes: We conducted a systematic overview, aiming to answer the following clinical questions: Does oral calcium supplementation during pregnancy reduce the risk and/or severity of pre-eclampsia? What are the effects of preventive calcium supplements pre-conception in women at risk of pre-eclampsia? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). Results: At this update, searching of electronic databases retrieved 109 studies. After deduplication and removal of conference abstracts, 55 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 30 studies and the further review of 25 full publications. Of the 25 full articles evaluated, one update of a previously included systematic review was added. We performed a GRADE evaluation for seven PICO combinations. Conclusions: In this systematic overview, we categorised the efficacy for three interventions based on information about the effectiveness and safety of calcium supplementation used to prevent pre-eclampsia, both during pregnancy and pre-conception, and different doses of calcium supplementation versus each other during pregnancy.
Many pregnant women gain excess weight during pregnancy which increases the health risks to the mother and her baby. Interventions to prevent excess weight gain need to be given to the whole population to prevent excess weight gain. The aim of this study was to assess the effectiveness of a simple and brief intervention embedded withinroutine antenatal care to prevent excessive gestation weight gain. Six hundred and ten pregnant women (between 10-14 weeks gestation), aged ≥18 years with a body mass index (BMI) ≥18.5 kg/m2, planned to receive community midwife led care or shared care at the time of recruitment are eligible to take part in the study. Women will be recruited from four maternity centres in England. Community midwives complete a short training module before delivering the intervention. In the intervention, midwives weigh women, set maximum weight limits for weight gain at each antenatal appointment and ask women to monitor their weight at home. Themaximum weight limit is adjusted by the midwife at each antenatal appointment if women have exceeded their maximum weight gain limit set at their previous appointment. The intervention will be compared with usual antenatal care. The primary outcome is the proportion of women per group who exceed the Institute of Medicine guidelines for gestational weight gain at 38 weeks of pregnancy according to their early pregnancy BMI category. The proposed trial will test a brief intervention comprising regular weighing, target setting and monitoring ofweight during pregnancy that can be delivered at scale as part of routine antenatal care. Using the professional expertise of community midwives, but without specialist training in weight management, the intervention will incur minimal additionalhealthcare costs, and if effective at reducing excess weight gain, is likely to be very cost effective. Trial registration Current controlled trials ISRCTN67427351. Date assigned 29/10/2014.
Non-diabetic ketoacidosis is increasingly recognised in pregnancy, particularly during the third trimester, and is usually associated with vomiting. In many cases, the cause of the vomiting is not identified and resolves rapidly, alongside the metabolic abnormalities, following delivery. Here, we report three cases in which pancreatitis was identified as an underlying cause of the gastrointestinal symptoms. To our knowledge, these are the first reports of pancreatitis precipitating non-diabetic ketoacidosis in pregnancy. This case series highlights the importance of searching for a precipitant for non-diabetic ketoacidosis in pregnancy, rather than focusing solely on management of the resulting metabolic abnormalities.
Assessing blood glucose (BG) control in women with gestational diabetes mellitus is challenging, as routine tests, for example HbA1c assessment, are an insensitive measure of response to the progressive changes of glucose regulation in pregnancy [1,2]. Consequently, the standard of care remains visual inspection of BG paper diaries of self-performed capillary monitoring. Numerous telehealth solutions to record BG readings have been developed, but their clinical superiority over standard care is yet to be shown . This article is protected by copyright. All rights reserved.
- Aug 2015
Objectives: To assess the diagnostic accuracy of placental growth factor (PlGF) and ultrasound parameters to predict delivery of a small-for-gestational-age (SGA) infant in women presenting with reduced symphysis–fundus height (SFH). Methods: This was a multicenter prospective observational study recruiting 601 women with a singleton pregnancy and reduced SFH between 24 and 37 weeks' gestation across 11 sites in the UK and Canada. Plasma PlGF concentration < 5th centile, estimated fetal weight (EFW) < 10th centile, umbilical artery Doppler pulsatility index > 95th centile and oligohydramnios (amniotic fluid index < 5 cm) were compared as predictors for a SGA infant < 3rd customized birth-weight centile and adverse perinatal outcome. Test performance statistics were calculated for all parameters in isolation and in combination. Results: Of the 601 women recruited, 592 were analyzed. For predicting delivery of SGA < 3rd centile (n = 78), EFW < 10th centile had 58% sensitivity (95% CI, 46–69%) and 93% negative predictive value (NPV) (95% CI, 90–95%), PlGF had 37% sensitivity (95% CI, 27–49%) and 90% NPV (95% CI, 87–93%); in combination, PlGF and EFW < 10th centile had 69% sensitivity (95% CI, 55–81%) and 93% NPV (95% CI, 89–96%). The equivalent receiver–operating characteristics (ROC) curve areas were 0.79 (95% CI, 0.74–0.84) for EFW < 10th centile, 0.70 (95% CI, 0.63–0.77) for low PlGF and 0.82 (95% CI, 0.77–0.86) in combination. Conclusions: For women presenting with reduced SFH, ultrasound parameters had modest test performance for predicting delivery of SGA < 3rd centile. PlGF performed no better than EFW < 10th centile in determining delivery of a SGA infant.
- Jun 2015
Objectives Cardiopulmonary exercise testing (CPET) is a well-established investigation used to stratify operative and anaesthetic risk as well as being predictive of cardiovascular morbidity and mortality. Pregnancy is a biological stress test and we hypothesised that CPET could risk stratify women with cardio-respiratory or metabolic disease during pregnancy. However, normal values in normal pregnancy are required before the predictive value of this test can be assessed in women with cardio-respiratory disease. This pilot study was designed to test the feasibility and tolerability of performing combined CPET and exercise echocardiography during pregnancy. Methods We prospectively recruited 10 women with a singleton pregnancy; all were healthy with no known medical conditions. Each participant attended at mean 14+1 (±2 days) (visit 1) and 24+5 (±3 days) (visit 2) weeks of gestation. At each visit participants had a resting echocardiogram, fetal ultrasound scan and baseline blood sample collected. A stepwise incrementing CPET was then performed with a maternal echocardiogram at maximal exertion. A blood sample was collected at maximal exertion. Results The participants had a mean age at visit 1 of 35 years (±4), 6 were nulliparous, BMI was 24.3 (±3.3). Combined CPET and exercise echo was successfully completed in all participants. There was no significant difference between visits for resting mean arterial pressure: 86.7 mmHg (±9.6) at visit 1 and 86.5 mmHg (±8.1) at visit 2 (p = 0.95), but resting left ventricular (LV) end diastolic volume increased from 77.3 ml (±15.1) in visit 1 to 83.8 ml (±17.2) in visit 2 (p = 0.008). Systolic function did not significantly change between visits, ejection fraction: 63.8% (±5.9) compared to 61.4% (±4.6) at visit 2 (p = 0.36). Diastolic function was not significantly altered. During the CPET test the peak workload achieved was similar at both visits: 165 Watts (±35.7) in visit 1 and 170 Watts (±36.9) in visit 2 (p = 0.51) as was VO2 max ml/Kg/min: 28.5 (±6.3) compared to 26.6 (±2.9) (p = 0.34). Respiratory exchange ratio (RER) increased significantly between visits: 1.05 (±0.05) compared to 1.11 (±0.05) at visit 2 (p = 0.01). Lactates collected increased from 1.1 mmol/L (range 0.9–1.7) before maximal exercise to 6.4 mmol/L (range 4.5–8.8) after in visit 1 (p < 0.001) and from 1.1 mmol/L (range 0.5–2.8) to 6.0 mmol/L (range 2.2–7.7) in visit 2 (p < 0.001). All participants delivered healthy live neonates at term gestation, however 1 participant developed pregnancy induced hypertension and 2 developed preeclampsia. Conclusions We successfully demonstrated combined exercise echo and CPET studies is well tolerated in pregnant women at 14 and 24 weeks gestation. We also demonstrated this combined test as a successful technique for capturing a wealth of metabolic and cardiac structural and functional data. Cardiac volumes increased between visits. RER increased which might suggest test familiarity.
To assess the diagnostic accuracy of placental growth factor (PlGF) and ultrasound parameters to predict delivery of a small-for-gestational-age (SGA) infant in women presenting with reduced symphysis-fundal height (SFH). Multicentre, prospective observational study recruiting 601 women with singleton pregnancies and reduced SFH between 24-37 weeks' gestation across 11 sites in UK and Canada. Plasma PlGF concentration <5(th) centile, estimated fetal weight (EFW) <10(th) centile, umbilical artery Doppler pulsatility index >95(th) centile and oligohydramnios (Amniotic Fluid Index <5 cm) were compared as predictors for a SGA infant <3(rd) customised birth weight centile (SGA-3) and adverse perinatal outcome. Test performance statistics were calculated for all parameters in isolation and combination. 592 women were analysed. For predicting delivery SGA-3 (n = 78), EFW <10(th) centile had 58% sensitivity (95%CI 46 to 69%) and 93% negative predictive value (NPV) (95%CI 90 to 95%), PlGF had 37% sensitivity (95%CI 27 to 49%) and 90% NPV (95%CI 87 to 93%); in combination, PlGF and EFW <10(th) centile had 69% sensitivity (95%CI 55 to 81%) and 93% NPV (95%CI 89 to 96%). The equivalent ROC areas were 0.79 (95%CI 0.74 to 0.84) for EFW <10(th) centile, 0.70 (95%CI 0.63 to 0.77) for low PlGF and 0.82 (95%CI 0.77 to 0.86) in combination. In women presenting with reduced SFH, ultrasound parameters had modest test performance for predicting delivery of SGA-3. PlGF performed no better than EFW <10(th) centile in determining delivery of a SGA infant. This article is protected by copyright. All rights reserved.
Background Cystic fibrosis manifests as a multisystem disease, despite this female fertility is relatively preserved with levels approaching that of the non-cystic fibrosis population. We reviewed pregnancies in cystic fibrosis patients over a 10-year period from a UK adult cystic fibrosis centre by considering maternal and fetal outcomes. Methods We conducted a retrospective case-note review of pregnancies during 2003–2013 using respiratory and obstetric records. Results We observed moderate falls in lung function immediately after delivery, which persisted at 12 months postpartum. We found that a decline in lung function at delivery was a marker for further decline in function during the subsequent postpartum period. We found baseline lung function was predictive of gestational age at delivery. We observed a high incidence of haemoptysis. Conclusion Consistent with current guidance we found pregnancy is feasible and well tolerated in the majority of patients with cystic fibrosis. There was a high incidence of haemoptysis, which warrants further study.
- Feb 2015
The goal of managing classical Hodgkin lymphoma (cHL) in pregnancy is to obtain good long-term outcomes for both the mother and fetus. Given the excellent outcomes outside of pregnancy, the goal of treatment should remain curative. There remains a tension and debate regarding the timing of chemotherapy, the curative nature of such treatment and the timing of delivery. Moreover, the aim during pregnancy should be to minimize fetal toxicity and optimize perinatal outcomes. The management of cHL within pregnancy was covered within the excellent recent British Committee for Standards in Haematology guidelines, but with necessary brevity. By reviewing the literature over the last 30 years, herein we discuss the options for management during each trimester. Critical organogenesis occurs between 2 and 8 weeks post-conception; during which time the immature fetus is vulnerable to cytotoxic exposure. We discuss the evidence for using ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) and single agent vinblastine in the first trimester. cHL presenting in pregnancy raises complex and difficult ethical dilemmas that can cause anxiety for patients, families and physicians. Decision-making must be multi-disciplinary and holistic, taking into account the patient's wishes, psycho-social and religious beliefs and personal circumstances. Clear communication between the haemato-oncologist, medical obstetrician, nurse specialists, midwives and neonatologists is paramount to a successful outcome.
- Jan 2015
An increasing number of women with complex cardiac disease are becoming pregnant which brings challenges for cardiologists, obstetricians and anaesthetists. Assessing risk and counselling patients prior to pregnancy is important; however, often women have unplanned pregnancies, or their cardiac condition is not diagnosed until during pregnancy. Normal pregnancy requires the mother to mount profound cardiovascular physiological changes, which can increase the risk of cardiac decompensation in women with underlying cardiac disease. Close monitoring by specialist multidisciplinary teams and detailed planning are essential to reduce both maternal and foetal risk. Changing patient demographics mean that there is an increase in women with complex congenital heart disease who require careful pre-conceptual evaluation and planning for their pregnancies. Another emerging problem is that of an increasing prevalence of atherosclerotic ischaemic heart disease in women of child-bearing years. Various risk stratification classifications are available to aid the clinician and patient alike. Management for most conditions remains close to that of the non-pregnant population, but risks associated with cardiovascular and obstetric drugs need to be borne in mind.
- Jan 2015
- Disorders of Thrombosis and Hemostasis in Pregnancy
Venous thromboembolism is a significant cause of maternal death in the UK, despite being a preventable condition for which clear risk factors have been identified. The introduction of routine antenatal and postnatal thromboprophylaxis for women identified by risk assessment tools has been linked to a steady reduction in the number of deaths. This chapter discusses the risk factors for the development of thromboembolism as well as the options for prophylactic intervention, and the specific clinical situations which can alter the treatment advice.
- Nov 2014
Guidelines encourage the use of self monitoring of blood pressure in pregnancy, and research suggests that women prefer it. But Hodgkinson and colleagues explain that our enthusiasm may run ahead of the evidence and call for more research before it is routinely adopted Self monitoring of blood pressure is increasingly popular with patients and healthcare professionals. Around a third of people with hypertension self monitor,1 and measurements are more accurate than readings taken in clinic.2 Anecdotal reports in the UK suggest that self monitoring in pregnancy is commonplace, although no studies have assessed this. A Canadian pilot survey found that two thirds of women with gestational hypertension were self monitoring.3 Another small Canadian survey found that 78% of obstetricians used self monitoring in preference to ambulatory measurement to check for white coat hypertension in pregnant women with raised blood pressure.4 Blood pressure guidelines recommend home monitoring for pregnant women with chronic hypertension and poorly controlled blood pressure and for women with gestational hypertension-for example, the 2013 American College of Obstetricians and Gynaecologists guidelines5-so it is likely that the practice will become more common. The American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association joint statement6 and European Society of Hypertension guidelines have highlighted the importance and potential of self monitoring blood pressure, with the American guidelines describing it as "theoretically ideal for monitoring changes in blood pressure during pregnancy."7 Although home monitoring in pregnancy may have some advantages, there are still many unanswered questions about its use (box 1). We discuss the available evidence on self monitoring and suggest a way forward.
- Oct 2014
The increase in gestational diabetes mellitus (GDM) is challenging maternity services. We have developed an interactive, smartphone-based, remote blood glucose (BG) monitoring system, GDm-health. The objective was to determine women's satisfaction with using the GDm-health system and their attitudes toward their diabetes care. In a service development program involving 52 pregnant women (September 2012 to June 2013), BG was monitored using GDm-health from diagnosis until delivery. Following birth, women completed a structured questionnaire assessing (1) general satisfaction, (2) equipment issues, and (3) relationship with the diabetes care team. Responses were scored on a 7-point Likert-type scale. Reliability and validity of the questionnaire were assessed using statistical methods. Of 52 women, 49 completed the questionnaire; 32 had glucose tolerance test confirmed GDM (gestation at recruitment 29 ± 4 weeks (mean ± SD), and 17 women previous GDM recommended for BG monitoring (18 ± 6 weeks). In all, 45 of 49 women agreed their care was satisfactory and the best for them, 47 of 49 and 43 of 49 agreed the equipment was convenient and reliable respectively, 42 of 49 agreed GDm-health fitted into their lifestyle, and 46 of 49 agreed they had a good relationship with their care team. Written comments supported these findings, with very positive reactions from the majority of women. Cronbach's alpha was .89 with factor analysis corresponding with question thematic trends. This pilot demonstrates that GDm-health is acceptable and convenient for a large proportion of women. Effects on clinical and economic outcomes are currently under investigation in a randomized trial (clinicaltrials.gov NCT01916694).
Gestational diabetes mellitus (GDM) is defined as new onset or recognition of glucose intolerance in pregnancy. Evidence supports tight blood glucose regulation to prevent adverse maternal and fetal outcomes. Finger-prick blood glucose (BG) testing with frequent clinic review remains the most common method of managing diabetes in pregnancy. The prevalence of GDM is rising globally, pressuring resource-limited services. We have developed an intuitive, interactive, reliable, and accurate management system to record BG measurements and deliver management of GDM remotely. Following an initial scoping phase, a prototype software application was developed using an Android smartphone with BG meter linkage via Bluetooth. A custom website was built for clinician review of the data transmitted by the smartphone. After system refinement, further evaluation was undertaken for usability and reliability in a 48-patient service development project. Women used the system for an average of 31.1 weeks. In all, 19 686 BG measures were transmitted, 98.6% of which had a meal tag. A total of 466 text messages were transmitted. A mean of 30 BG readings per woman per week were transmitted, and 85% of women submitted the minimum requirement of 18 readings per week. We have developed a novel, real-time, smartphone-based BG monitoring management system that allows clinician review of real-time patient-annotated BG results. Results indicate high usage and excellent compliance by women. Robust clinical, economic, and satisfaction evaluations are required. To address these requirements, we are currently conducting a randomized controlled pilot trial.
Hypertensive disorders of pregnancy are a major contributor to death and disability for pregnant women and their infants. The diagnosis of preeclampsia by using blood pressure and proteinuria is of limited use because they are tertiary, downstream features of the disease. Placental growth factor (PlGF) is an angiogenic factor, a secondary marker of associated placental dysfunction in preeclampsia, with known low plasma concentrations in the disease. In a prospective multicenter study, we studied the diagnostic accuracy of low plasma PlGF concentration (<5th centile for gestation, Alere Triage assay) in women presenting with suspected preeclampsia between 20 and 35 weeks' gestation (and up to 41 weeks' gestation as a secondary analysis). The outcome was delivery for confirmed preeclampsia within 14 days. Of 625 women, 346 (55%) developed confirmed preeclampsia. In 287 women enrolled before 35 weeks' gestation, PlGF <5th centile had high sensitivity (0.96; 95% confidence interval, 0.89-0.99) and negative predictive value (0.98; 0.93-0.995) for preeclampsia within 14 days; specificity was lower (0.55; 0.48-0.61). Area under the receiver operating characteristic curve for low PlGF (0.87, standard error 0.03) for predicting preeclampsia within 14 days was greater than all other commonly used tests, singly or in combination (range, 0.58-0.76), in women presenting with suspected preeclampsia (P<0.001 for all comparisons). In women presenting before 35 weeks' gestation with suspected preeclampsia, low PlGF has high sensitivity and negative predictive value for preeclampsia within 14 days, is better than other currently used tests, and presents an innovative adjunct to management of such women.
Free-text comments in multi-source feedback are intended to facilitate change in the assessee's practice. This study was designed to utilise a large dataset of free-text comments obtained in a national pilot study in order to investigate how helpful these free-text comments may be to assessees. We investigated: (i) which areas of performance are usually addressed by free-text comments; (ii) to what extent assessors' (doctors, nurses, allied health professionals and clerical or managerial staff) comments correspond to assessees' (career-grade doctors) self-assessments, and (iii) whether the comments contain specific behavioural evidence and suggestions for change. Initially comments were read through to identify commonly recurring themes. A strong theme was 'respondent-centredness', which refers to the extent to which comments focus on issues that are of value to the assessor rather than to the assessee's personal development. In response to this, the data were re-evaluated against predefined research questions to assess how constructive comments were for the assessee's personal development. Of 11 483 assessor forms, 4777 (42%) included free-text comments. A total of 513 forms contained at least one below average score and 286 (56%) of these forms contained the assessor's free-text feedback. Free-text comments were mostly rater-centred and addressed the effect of the assessee on the colleague's working life rather than areas of relevance to the assessee's personal development. A total of 1806 assessor/assessee pairs of comments were compared; most demonstrated clear differences of opinion or interpretation. Reliability and supportiveness were over-represented; clinical performance and personal development were under-represented. The comments were unlikely to provide specific behavioural evidence or to address how change might be initiated. Our data indicate that, in their current form, the overwhelming majority of free-text comments add little to facilitate improvement in assessees' personal development and performance.
- Jun 2013
Background Cystic fibrosis manifests as a multisystem disease, despite this female fertility is relatively preserved with levels approaching that of the non-cystic fibrosis population. We reviewed pregnancies in cystic fibrosis patients over a 10-year period from a UK adult cystic fibrosis centre by considering maternal and fetal outcomes.
Neurological diseases are a major cause of morbidity and mortality in pregnancy. The management of multiple sclerosis, epilepsy, myasthenia gravis, certain neuropathies and headache in pregnancy is described; the potentially life-threatening conditions of stroke and eclampsia are also discussed. Management of most neurological conditions is similar to outside of pregnancy, but special consideration should be given to delivery plans and the safety of medications antenatally and during breastfeeding. Pre-pregnancy counselling, regular review and effective communication among a multi-disciplinary team are key to optimising management and outcomes.
- Feb 2013
Vaccinations in pregnancy are known to be cost-effective means of preventing disease. They may be recommended primarily for maternal benefit or for the prevention of intrauterine infection of the fetus. Increasingly they are a recognized technique of providing protection to the newborn through passive immunity and by reducing disease exposure.Theoretical concerns regarding adverse effects to the fetus and lack of efficacy have, in general, not been confirmed by clinical evidence. Nevertheless live attenuated vaccines remain contraindicated due to the risk of fetal infection. As with any clinical decision, advice on antenatal vaccination should be based on the balance of risks and benefits to mother and fetus. This article aims to guide such decisions by discussing some of the issues surrounding commonly used vaccines and presenting current UK guidelines.
- Jan 2013
Ornithine transcarbamylase (OTC) deficiency is the most common inborn error in the metabolism of the urea cycle with an incidence of 1 in 14 000 live births. Pregnancy can trigger potentially fatal hyperammonemic crises. We report a successful pregnancy in a 29-year-old primiparous patient with a known diagnosis of OTC deficiency since infancy. Hyperammonemic complications were avoided due to careful multidisciplinary management which included a detailed antenatal, intrapartum and postnatal plan. Management principles include avoidance of triggers, a low-protein diet and medications which promote the removal of nitrogen by alternative pathways. Triggers include metabolic stress such as febrile illness, particularly gastroenteritis, fasting and any protein loading. In our case the patient, in addition to a restricted protein intake, was prescribed sodium benzoate 4 g four times a day, sodium phenylbutyrate 2 g four times a day and arginine 500 mg four times a day to aid excretion of ammonia and reduce flux through the urea cycle.
Cardiac disease is the leading cause of maternal mortality in the UK. The major causes of cardiac deaths in pregnancy include cardiomyopathy, myocardial infarction, ischaemic heart disease and dissection of the thoracic aorta. With increasing numbers of migrant women in the UK, rheumatic heart disease in pregnancy has also re-emerged. Women with uncorrected congenital heart disease and those who have undergone corrective or palliative surgery may have complicated pregnancies. Women with metal prosthetic valves face difficult decisions regarding anticoagulation in pregnancy and have an increased risk of haemorrhage. Not all women with significant heart disease are able to meet the increased physiological demands of pregnancy. The care of pregnant women with heart disease thus requires a multidisciplinary approach, involving obstetricians, cardiologists and anaesthetists. This allows appropriate surveillance of maternal and fetal wellbeing, as well as planning and documentation of the management of elective and emergency delivery. This review discusses common cardiac conditions encountered in pregnancy and their antenatal and intrapartum management.
- Nov 2012
Starvation ketosis outside pregnancy is rare and infrequently causes a severe acidosis. Placental production of hormones, including glucagon and human placental lactogen, leads to the insulin resistance that is seen in pregnancy, which in turn increases susceptibility to ketosis particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis is likely to have important implications for fetal survival as ketoacidosis in women with type 1 diabetes mellitus is associated with intrauterine death. This article features four cases of women with vomiting in the third trimester of pregnancy associated with a severe metabolic acidosis. The mechanism underlying ketogenesis, the evidence for accelerated ketogenesis in pregnancy and other similar published cases are reviewed. A proposed strategy for management of these women is presented.
- Oct 2012
Risk of hypertension in mother and offspring after preeclampsia is greater if preeclampsia develops early in pregnancy. We investigated whether those who develop early onset disease have unique adverse blood pressure characteristics. One hundred forty women were studied 6 to 13 years either after a pregnancy complicated by preeclampsia (45 women with early onset preeclampsia before 34 weeks gestation and 45 women with late-onset preeclampsia) or after a normotensive pregnancy (50 women). Forty-seven offspring from these pregnancies also participated. Data on maternal antenatal and postnatal blood pressures were extracted from maternity records and related to peripheral, central, and ambulatory blood pressure measurements in later life. Compared with late-onset preeclampsia, early onset preeclampsia was associated with higher diastolic blood pressure 6 weeks postnatally (86.25±13.46 versus 75.00±5.00 mm Hg, P<0.05), a greater increase in blood pressure relative to booking blood pressure over the subsequent 6 to 13 years, and higher nocturnal systolic and diastolic blood pressures in later life (111.07±13.18 versus 101.13±11.50 mm Hg, P=0.04, and 67.00±7.25 versus 58.60±5.79 mm Hg, P=0.002). Furthermore, at age 6 to 13 years their offspring had higher systolic blood pressure compared with those born to late-onset preeclampsia (96.27±7.30 versus 88.39±7.57 mm Hg, P=0.005). Mothers who developed early onset preeclampsia, and the offspring of that pregnancy display specific adverse blood pressure characteristics later in life. These are not evident in mothers and offspring after late-onset preeclampsia or normotensive pregnancy.
- Sep 2012
Background: There is concern over ionizing radiation exposure in women who are pregnant or of child-bearing age. Due to the increasing prevalence of congenital and acquired heart disease, the number of women who require cardiac interventions during pregnancy has increased. We have developed protocols for cardiac interventions in pregnant women and women of child-bearing age, aimed at substantially reducing both fluoroscopy duration and radiation doses. Methods: Over five years, we performed cardiac interventions on 15 pregnant women, nine postpartum women and four as part of prepregnancy assessment. Fluoroscopy times were minimized by simultaneous use of intracardiac echocardiography, and by using very low frame rates (2/second) during fluoroscopy. Results: The procedures most commonly undertaken were closure of atrial septal defect (ASD) or patent foramen ovale (PFO) in 16 women, coronary angiograms in seven, right and left heart catheters in three and two stent placements. The mean screening time for all patients was 2.38 minutes (range 0.48-13.7), the median radiation dose was 66 (8.9-1501) Gy/cm(2). The median radiation dose to uterus was 1.92 (0.59-5.47) μGy, and the patient estimated dose was 0.24 (0.095-0.80) mSv. Conclusions: Ionizing radiation can be used safely in the management of severe cardiac structural disease in pregnancy, with very low ionizing radiation dose to the mother and extremely low exposure to the fetus. With experience, ionizing radiation doses at our institution have been reduced.
- Jul 2012
Our aim was to directly assess the postnatal mobility of mothers and to relate and compare venous thromboembolism (VTE) risk with current guidelines on VTE thromboprophylaxis postpartum. VTE still remains one of the leading causes of direct maternal deaths in the western world and this risk is greatest in the postnatal period. Mode of delivery and postnatal mobility are key, however the effect of the former on the latter is unclear. A total of 200 antenatal women were recruited into the study. Each was given a pedometer and recorded the number of steps taken daily for 7 days postpartum. A total of 72 women completed the study. Those who underwent any form of vaginal delivery were mobile soonest. By day 7 postpartum, women following vaginal delivery were almost twice as mobile as those who underwent caesarean section (CS). Women who underwent emergency CS were more mobile than those who had elective CS, which is contrary to current assumptions.
Introduction Pre-eclampsia (PET) contributes significantly to maternal morbidity and mortality. Aspirin prescription is recommended to reduce the incidence of PET. Aspirin treatment for PET prevention was audited against NICE guidelines. Prescriber knowledge was explored to identify whether this was a factor in poor compliance with NICE guidance. Methods A retrospective audit of deliveries at both a teaching and district general hospital was performed over a 1 month period. Patients' risk of PET according to NICE guidance and subsequent aspirin prescription was noted. Prescriber knowledge was surveyed in both units. Included in this were 16 patient scenarios, 9 of which alluded to aspirin treatment. Results In district general and teaching hospitals respectively, 14.6% and 21.0% of patients were eligible for aspirin; with 6.4% and 30.8% of those eligible receiving treatment. Prescriber knowledge was best at ST3-5 level. 90.9% of prescribers were aware that aspirin was used to reduce the incidence of PET. Correct identification of ‘theoretical risk’ and eligibility for aspirin ranged between 18.8-100%, mean 65.6%. All knew the recommended dose. 40.9% would commence treatment from 12/40, 50% from conception and 9.1% between 16-20/40. 69.9% would stop treatment at delivery. Conclusions Prescribers are aware of aspirin use in prevention of PET, with reasonable theoretical knowledge of risk and need for treatment. However, this fails to translate into clinical practice. In both hospitals a significant number of patients qualify for aspirin treatment, but <1/3rd of patients are receiving treatment. Authors recommend that risk assessments for aspirin be incorporated into patient's notes.
Introduction Pituitary apoplexy is a clinical syndrome of selective or multi-hormonal pituitary failure, classically described as a result of infarction of a pre-existing pituitary adenoma associated with pituitary or peri-pituitary haemorrhage. Previous reports in pregnancy have described pituitary apoplexy complicating macroprolactinomas, growth-hormone secreting tumours, and auto-immune lymphocytic hypophysitis. Radiological diagnosis is difficult, particularly with the reticence to use contrast media in pregnancy. In addition, the profound changes in most pituitary axes during pregnancy complicate interpretation of hormone levels. Case study MI, a 31-year-old with three previous low-risk pregnancies, presented with recurrent new-onset unexplained collapse from 28- to 33-weeks gestation. The history was suggestive of vaso-vagal episodes; precipitated by headache, or prolonged standing. However, progressive frequency, spontaneous onset at rest and generalised seizure activity necessitated further investigation. Electrocardiogram, echocardiogram and continuous cardiac monitoring during episodes demonstrated no cardiological cause. No neurological deficit was demonstrated. Following transfer to a tertiary centre, magnetic resonance imaging identified changes in-keeping with acute haemorrhage within an enlarged pituitary gland, consistent with pituitary apoplexy. A short synacthen test suggested sub-optimal pituitary-adrenal axis function. No other pituitary deficiency was demonstrated. MI was treated medically with steroid replacement therapy and proceeded to term with emergency caesarean section for failure to progress. Discussion Hypopituitarism can present insidiously with variable involvement of trophic hormonal axes. It is plausible that the increased frequency and severity of the episodes was a presenting feature of progressive corticotrophin deficiency, reinforced by clinical improvement on steroid replacement.
Most deaths are now caused by preventable or treatable medical conditionsSince the first report of the Confidential Enquiry into Maternal Deaths in 1952, the maternal death rate in the United Kingdom has decreased dramatically.1 This has been due to an impressive fall in deaths with direct obstetric causes, including obstetric haemorrhage, ectopic pregnancy, and venous thromboembolism. This has partly been achieved through better understanding of obstetric complications, advances in medical treatments, and the use of evidence based guidelines that implement recommendations made in previous reports.2 However, almost 60 years since the first Confidential Enquiry into Maternal Deaths report, the most recent report, published in March 2011, highlights a worrying trend in the causes of maternal mortality in the UK.1The report states that most maternal deaths in the UK now occur in women with pre-existing or new onset medical and psychiatric conditions (“indirect causes”). The leading cause of maternal death remains cardiac disease; the second is neurological disease. Most worryingly, the number of maternal deaths due to indirect causes has significantly increased over the past 20 years (table⇓). Furthermore, most of these deaths are associated with substandard care, and in one third of cases this is classified as major substandard care, where different care might have prevented death of …
Multi-source feedback (MSF) provides a window into complex areas of performance in real workplace settings. However, because MSF elicits subjective judgements, many respondents are needed to achieve a reliable assessment. Optimising the consistency with which questions are interpreted will help reliability. We compared two parallel forms of an MSF instrument with identical wording and administration procedures. The original instrument contained 10 compound performance items and was used 12,540 times to assess 977 doctors, including 112 general practitioners (GPs). The modified instrument contained the same wording in 21 non-compound items, each of which asked about a single aspect of performance, and was used 2789 times to assess 205 doctors, all of whom were GPs. Generalisability analysis evaluated questionnaire reliability. The reliability of the original instrument was evaluated for both the whole group and the GP subgroup. The two instruments provided similar numbers of responses per doctor. The modified instrument generated more reliable scores. The whole-group comparison examined precision, measured as standard error of measurement (SEM); seven respondents were sufficient to achieve a 95% confidence interval of 0.25 (on a 4-point scale) with the modified instrument, compared with 10 respondents using the original instrument. The subgroup comparison examined the generalisability coefficient; 15 responses provided a reliability of 0.72 using the modified instrument or 0.58 using the original instrument. Non-compound questions improved the consistency of scores. We recommend that compound questions be avoided in assessment instrument design.
- Jun 2011
Introduction As recommended by the National Collaborating Centre for Women's and Children's Health, our protocol screens for anaemia in pregnancy at booking and at 30 weeks. Iron supplementation is offered if Hb ≤11 g/100 ml or mean cell volume (MCV) <82 fl. If Hb ≥11 g/100 ml, ferritin is measured and iron supplementation is offered if ferritin ≤ 30 mcg/l. Aims The aims were to establish adherence to national guideline and the characteristics of the red cell indices and ferritin as gestation advances. Methods The first 50 consecutive women delivered from the January 1 2009 were selected. Information was obtained from hospital notes and laboratory records. Results From the 50 women, 168 FBC samples were taken. The mean Hb, MCV and haematocrit (HCT) were 11.9 g/100 ml±0.9 (range 9.2–13.8); 88.0 fl±4.6 (range 72.1–97.2); and 0.35±0.03 (range 0.28–0.40) respectively. Both booking and 30 week FBC were done in 40 (92%) cases; 3 (6%) at 30 week (due to transfer of care from other units) and 1 (2%) at booking. 27 (54%) of the 50 women had MCV<82 or Hb ≤11 at any time. 18 (67%) has documentation of prescribed iron. Where Hb>11.0, ferritin was measured in 16 (32%) of cases and 82% had ferritin ≤30 mcg/dl. Conclusion Adherence to guideline is good (98%) for blood sampling but less good (67%) in the prescription of iron. Where Hb ≥11 g/100 ml, majority (82%) had ferritin ≤30 mcg/dl. Hb and HCT tend to fall in second trimester and rises again in the third trimester. MCV tends to rise slightly and steadily throughout gestation.
- Apr 2011
Prescribing in pregnancy often causes uncertainty and anxiety for the clinician and may lead to the omission of necessary treatment. Many drugs have inadequate data to assure safety, and therefore the clinician is left with a dilemma as to where the balance of risks and benefits lie with respect to the mother and her fetus. Understanding under what circumstances women can be prescribed medication and using principles of prescribing in pregnancy to further clarify the potential risks will aid good clinical decision-making. An appreciation of the available resources and the conviction to find the best available evidence will best serve the patient and her fetus. Teratogenicity refers to the potential for a drug to cause fetal malformations and affects the embryo 3-8 weeks after conception. Teratogenic drugs are associated with an increased risk of malformations, but the majority of babies are born with no abnormalities. In addition, approximately 2-3% of infants are born with major malformations with no association with maternal medication, and this and other confounding factors need to be addressed during counselling of a woman. Fetotoxicity refers to the functional changes that can occur to the fetus as a result of medication in the second and third trimesters. These effects are more subtle and more difficult to assess and therefore there are fewer data to support or refute these types of associations. For the majority of drugs, the neonatal dose from breast feeding is a fraction of the dose exposure in utero.
The UK Department of Health is considering a single, generic multi-source feedback (MSF) questionnaire to inform revalidation. Evaluation of an implementation pilot, reporting: response rates, assessor mix, question redundancy and participants' perceptions. Reliability was estimated using Generalisability theory. A total of 12,540 responses were received on 977 doctors. The mean time taken to complete an MSF exercise was 68.2 days. The mean number of responses received per doctor was 12.0 (range 1-17) with no significant difference between specialties. Individual question response rates and participants' comments about questions indicate that some questions are less appropriate for some specialities. There was a significant difference in the mean score between specialities. Despite guidance, there were significant differences in the mix of assessors across specialties. More favourable scores were given by progressively more junior doctors. Nurses gave the most reliable scores. It is feasible to electronically administer a generic questionnaire to a large population of doctors. Generic content is appropriate for most but not all specialties. The differences in mean scores and the reliability of the MSF between specialties may be in part due to the specialty differences in assessor mix. Therefore the number and assessor mix should be standardised at specialty level and scores should not be compared across specialties.
Objectives The authors aim to directly assess the mobility of Mothers following delivery and subsequently aim to relate and compare venous thromboembolism (VTE) risk with current guidelines on VTE thromboprophylaxis post partum.BackgroundVTE still remains the leading cause of direct maternal deaths in the western world and this risk is greatest in the postnatal period. Mode of delivery and postnatal mobility are extremely important contributory factors.Materials and Methods200 antenatal women were recruited into the study. Each was given a pedometer (digital step counter) and record sheet for recording the number of steps taken daily for 7-day post partum.Results72 women completed the study. The distribution according to delivery mode were as follows; spontaneous vertex delivery (SVD) =21, vaginal instrumental =21, elective Caesarean section (CS) =20, emergency CS =10. Mothers who underwent vaginal instrumental deliveries had the longest labours followed by SVD then emergency CS. However those who underwent any form of vaginal delivery were first mobile. By day 7 post partum, women following vaginal delivery were almost twice as mobile than those who underwent CS. Interestingly, women who underwent emergency CS were more mobile than those who had elective CS. Raised body mass index was an important contributory factor.SummaryThere are a number of contributory risk factors for VTE. Assumptions regarding mobility according to delivery mode must not be made. Continous individual risk assessment from preconception to post partum is essential in reducing VTE morbidity and mortality.
Inflammatory bowel diseases (IBD) typically affect patients in their reproductive years. It has been shown that reproductive issues are of key concern to IBD patients,1 especially women.2 In this respect, it is important to note that IBD patients remain voluntary childless more frequently than non-IBD controls.1,3,4 A recent study reported that IBD patients refrain from having children due the concerns about the adverse reproductive outcome.1 Fear of side-effects of the medication on the child and medical advice given by physicians, were the most important reasons for voluntary childlessness in this study. The treatment of IBD patients wishing to conceive is surrounded with uncertainties both for the parents to be and the treating physician. This guideline is developed to address these uncertainties and to promote a European perspective on reproduction in inflammatory bowel disease patients. The strategy to reach consensus involved the following steps: 1. The development of questions that should be covered by these pregnancy guidelines. Participants were asked to review these questions and when necessary to adjust or add questions. 2. The participants met in London in November to agree on the questions 3. The participants performed a systematic literature search of their topic with the appropriate key words using Medline/Pubmed and the Cochrane database, as well as their own files. The evidence level was graded (Table 1) according to the Oxford Centre for Evidence-Based medicine 5. 4. Provisional statements of the participants were written and the participants met in Prague in February 2010 to agree on the statements. This was done by projecting the statements and revising them on screen until a consensus was reached. Consensus was defined as agreement by > 80% of the participants. Each recommendation was graded as stated above. 5. The final document on each topic was written by the …
- Apr 2010
Our series Prescribing in pregnancy provides guidance on what information to offer pregnant women about the risks and benefits of drug treatment. Here the authors discuss the course of asthma during pregnancy and the use and safety of asthma medications. Copyright © 2010 Wiley Interface Ltd
- Mar 2010
The presence of abnormal liver function is common in pregnancy. It can be a challenge to elucidate the cause. The history and clinical assessment provide useful tools for distinguishing between pregnancy-related causes, such as pre-eclampsia, acute fatty liver of pregnancy and obstetric cholestasis, and non pregnancy-related causes such as non-alcoholic fatty liver disease, acute viral infection, autoimmune liver disease and Budd–Chiari syndrome. Pregnancy may also affect the natural course of liver conditions, for example, by increasing the risk of haemorrhage from a hepatic adenoma, or the severity of hepatitis E infection. It is important for clinicians to be aware of the impact that liver disorders and the drugs used to treat them have on pregnancy and to understand the influence of pregnancy on specific liver disorders.
- Aug 2007
Purpose – In light of the recent report on regulation by the CMO of England and Wales and the subsequent Department of Health White Paper, this paper aims to consider the nexus between revalidation, appraisal and clinical governance. It provides a summary of the history of revalidation in the UK and explores how revalidation is linked to annual appraisal. It further considers the implications of this relationship and its potential impact on clinical governance and practise. Design/methodology/approach – This is a policy review related to revalidation and appraisal including primary sources from the Department of Health, the GMC, Fifth report of the Shipman Inquiry and published journal articles. Findings – Local clinical governance will be a significant part of the route to re-licensing for the vast majority of doctors working in the NHS and many of the larger private sector hospitals. Although it will be used for two different purposes, it is generally accepted that the information collected by doctors for their annual appraisal will also form the basis of evidence for revalidation. If appraisal is to be effective, robust and consistent, it is important that the clinical governance framework within which it operates is appropriately designed for its increased role within the regulatory system. Originality/value – This paper is a valuable summary and introduction to the concept of revalidation in the UK, its history and its impact on clinical governance and regulation. It provides a timely review and analysis of the proposed changes to clinical governance at the local, SHA level and the strengthened connection between consultant appraisal and revalidation, contained in both the Department of Health White Paper – Trust, Assurance and Safety and the report – Good Doctors, Safer Patients, by the Chief Medical Officer for England and Wales.
- Jun 2006
There has been increasing interest in methods of assessing patients' experience or satisfaction with their doctor and this is particularly relevant in light of the recent publication of Good Doctors, Safer Patients by the Chief Medical Officer. Methods of assessment that measure what a doctor actually does in real-life practice, rather than what they are competent to do in a simulated environment, are particularly powerful tools that have been under-utilised in the past. While there are many published patient surveys, most address the patient's whole experience of the healthcare episode rather than focusing on the doctor's performance in areas such as interpersonal skills, communication skills and professionalism. Here we describe our experience of developing a patient survey to support consultant appraisal and revalidation, in collaboration with the Royal College of Physicians' Patient and Carer Network.