Holly Casele

Prospective evaluation of bone density in pregnant women receiving the low molecular weight heparin enoxaparin sodium.

OBJECTIVE To evaluate changes in bone density in women receiving enoxaparin sodium during pregnancy. METHODS Bone density in the proximal femur was serially measured in 16 women receiving enoxaparin sodium (40 mg daily) during pregnancy. Baseline measurements were taken within 2 weeks of starting therapy and then at 6-8 weeks postpartum and 6 months postpartum. RESULTS Patients received enoxaparin sodium for a mean duration of 25 weeks (range, 19-32 weeks). There was no significant change in mean bone density measurement from baseline measurements to the conclusion of therapy at 6 weeks postpartum and no patient experienced a decrease in bone mass of >10% at 6 weeks postpartum. By 6 months postpartum, there was a significant mean decrease in bone density (P = 0.02) and two of the 14 patients evaluated (14%) experienced an overall bone loss of >10%. CONCLUSION The prolonged used of enoxaparin sodium may not cause significant bone loss during pregnancy.

Pregnancy after liver transplantation

This article reviews the reported experience with pregnancy after liver transplantation and describes obstetric risks and medical issues that the maternal fetal medicine specialist has a reference for managing these pregnancies and for providing appropriate preconception counseling. Women who undergo liver transplantations have a higher risk of preeclampsia, worsening hypertension, preterm premature rupture of membranes, anemia, small for gestational age, preterm delivery, and cesarean section than the normal obstetric population. Women with preconceptional renal dysfunction appear to be at greatest risk for pregnancy complications. Women who conceived within 6 months of transplant had a high risk of rejection. Reproductive-aged recipients of liver allograft should receive contraception and preconception counseling. In an appropriately timed and planned pregnancy, women who undergo liver transplantations can have successful pregnancies with little risk to their allograft function.

Association of pregnancy complications and choice of immunosuppressant in liver transplant patients.

BACKGROUND The purpose of this study was to identify factors associated with antenatal complications for an ongoing series of pregnant women who have undergone orthotopic liver transplantation. METHODS We reviewed Magee-Womens Hospital records from 14 pregnancies in 13 women in whom a liver had been transplanted before pregnancy. We collected and analyzed data regarding the primary liver disease, allograft status, liver function at conception and during pregnancy, immunosuppressive medications, associated medical conditions, time from transplant to conception, cytomegalovirus serostatus, and maternal and fetal outcome. RESULTS Seven patients had evidence of renal dysfunction (creatinine, 1.3-2.0 mg/dl), five of whom also were hypertensive at their first prenatal visit. The complications of preeclampsia, worsening hypertension, and small for gestational age occurred only in women with renal dysfunction at conception. Renal dysfunction was more often associated with cyclosporine than tacrolimus use. CONCLUSIONS Renal dysfunction is the primary determinant of adverse pregnancy outcome in liver transplant recipients. Immunosuppression with cyclosporine during pregnancy was more often associated with antenatal complications than with the use of tacrolimus.

Cost-effectiveness of thromboprophylaxis with intermittent pneumatic compression at cesarean delivery.

OBJECTIVE: To evaluate the cost-effectiveness of thromboprophylaxis at cesarean delivery with intermittent pneumatic compression. METHODS: A decision tree model using Markov analysis was developed to compare two approaches to perioperative care at the time of cesarean delivery: 1) no use of perioperative thromboprophylaxis and 2) the use of intermittent pneumatic compression for thromboprophylaxis at the time of cesarean delivery. Postcesarean deep venous thrombosis was estimated to occur in 0.7% of patients (75% of whom were asymptomatic), and result in a 9% chance of postthrombotic syndrome. Mechanical prophylaxis was assumed to decrease the risk of deep venous thrombosis by 70% and to cost

Metabolic response to meal eating and extended overnight fast in twin gestation

120. Probability of morbidity and mortality of venous thromboembolism as well as anticoagulation and the costs and utilities for different health state were derived from published studies. Sensitivity analysis was performed over a wide range of variable estimates. RESULTS: Using the assumptions in our base case, routine thromboprophylaxis for cesarean delivery cost

Prenatally Diagnosed Vasa Previa: A Single-institution Series of 96 Cases

39,545 per quality-adjusted life year. One-way sensitivity analysis revealed that as long as the incidence of postcesarean deep venous thrombosis was at least 0.68%, intermittent pneumatic compression reduced the incidence of deep venous thrombosis by at least 50%, or the cost of intermittent pneumatic compression was less than

Ultrafast magnetic resonance imaging of cephalopagus conjoined twins

180, the cost-effectiveness of mechanical prophylaxis did not exceed

Comparison of Active Phase Labor Between Triplet, Twin, and Singleton Gestations:

50,000 per quality-adjusted life year. CONCLUSION: Mechanical thromboprophylaxis is estimated to be a cost-effective strategy under a wide range of circumstances. LEVEL OF EVIDENCE: III

FACTORS INFLUENCING PRECONCEPTION CONTROL OF GLYCEMIA IN DIABETIC WOMEN

OBJECTIVE Our purpose was to compare the metabolic response to normal meal eating and the vulnerability to starvation ketosis in twin versus singleton gestation. STUDY DESIGN Data are reported on 10 twin and 10 singleton nondiabetic gestations enrolled in a 40-hour metabolic study. Singletons were age (+/- 5 years) and prepregnancy weight (+/- 10% ideal body weight) matched with twins. The diet (35 kcal/kg ideal body weight for singletons, 40 kcal/kg ideal body weight for twins) was distributed as one fifth at 8 AM, two fifths at 1 PM, and two fifths at 6 PM. An overnight fast was extended until noon the following day. Glucose and beta-hydroxybutyrate measurements were made hourly except at night, when they were made every 2 hours. Insulin values were obtained before and after dinner and on the day when breakfast was delayed. RESULTS The glucose, beta-hydroxybutyrate, and insulin excursions in response to meal eating from 8 AM to 12:00 noon on day 1 were similar in twin and singleton pregnancies (analysis of variance for repeated measures, p < 0.05). On day 2, when breakfast was delayed, a progressive decrement in glucose was observed in both twins and singletons (p = 0.4682). Concurrently, there was a progressive rise in beta-hydroxybutyrate in both twins and singletons, which was significantly greater for twins compared with singletons (p = 0.002). CONCLUSIONS These data indicate that twin gestations are more vulnerable to the accelerated starvation of late normal pregnancy than singletons are in spite of additional caloric intake. We speculate that the observed difference may be the result of the increased metabolic demands of twin gestation.

Puerperal thromboprophylaxis: comparison of the anti‐Xa activity of enoxaparin and unfractionated heparin

OBJECTIVE: To describe outcomes for a large cohort of women with prenatally diagnosed vasa previa, determine the percentage in patients without risk factors, and compare delivery timing and indications for singletons and twins. METHODS: This was a retrospective case series of women with prenatally diagnosed vasa previa delivered at a single tertiary center over 12 years. Potential participants were identified using hospital records and perinatal databases. Patients were included if vasa previa was confirmed at delivery and by pathologic examination. Maternal and newborn data were gathered from medical records. RESULTS: There were 77 singleton and 19 twin pregnancies with a prenatal diagnosis of vasa previa. There was one neonatal death from congenital heart disease. Perinatal management of recommended elective hospitalizations with corticosteroid administration and elective early delivery resulted in average gestational age for delivery in singletons at 34.7±1.6 weeks and 32.8±2.2 weeks for twins. Among the 77 singletons, delivery was elective in 48, as a result of contractions or labor in 21, bleeding in four, nonreassuring tracing in two, asymptomatic cervical shortening in one, and preeclampsia in one. Among 19 twins, delivery was elective in six and for contractions or labor in 13. Sixty-eight percent of twins compared with 37% of singletons had nonelective delivery (P<.05). Delivery occurred by 32 weeks of gestation in 6.4% of singletons and 26% of twins (P<.05) and by 34 weeks of gestation in 11% of singletons and 58% of twins (P<.001). Six neonates (5.2%) had major anomalies, all prenatally detected. Respiratory distress syndrome occurred in 57.1% of singletons and 65.7% of twins. Nineteen singletons (24.7%) had no risk factors for vasa previa. CONCLUSION: Planned preterm delivery for women with prenatally diagnosed vasa previa resulted in elective delivery for singletons in 62% and for twins 32%. Gestational age at birth on average was 34.7 weeks for singletons and 32.8 weeks of gestation for twins. Major anomalies were frequent as was respiratory distress syndrome. Elective delivery between 34 and 35 weeks of gestation for singletons is reasonable. As a result of the high rate of nonelective delivery in twins, delivery at 32–34 weeks of gestation may be risk-beneficial. The high rate of singletons without risk factors for vasa previa reinforces the recommendation to screen routinely for cord insertion site.