Jennifer Hogan

Prospective risk of fetal death in uncomplicated monochorionic twins

A retrospective cohort study was carried out in a university teaching hospital to determine the prospective risk of unexpected fetal death in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies after viability. All MCDA twins delivered at or after 24 weeks’ gestation from July 1999 to July 2007 were included. Pregnancies with twin–twin transfusion syndrome, growth restriction, structural abnormalities, or twin reversed arterial perfusion sequence were excluded. Of the 144 MCDA twin pregnancies included in our analysis, the risk of intrauterine death was 4.9%. The prospective risk of unexpected intrauterine death was 1 in 43 after 32 weeks’ gestation and 1 in 37 after 34 weeks’ gestation. Our results demonstrate that despite close surveillance, the unexpected intrauterine death rate in uncomplicated MCDA twin pregnancies is high. This rate seems to increase after 34 weeks’ gestation, suggesting that a policy of elective preterm delivery warrants evaluation.

Maternal mortality and the rising cesarean rate

To review maternal mortality in a large stand‐alone maternity hospital in a European city and to determine whether the increased cesarean rate was associated with an increase in maternal deaths.

Peripartum hysterectomy in the first decade of the 21st century

Summary We reviewed the role of peripartum hysterectomy (PH) in the first decade of the 21st century. The study was confined to women who delivered a baby weighing 500 g or more between 2000 and 2009, and who required a hysterectomy within 72 h of delivery for obstetric reasons. Individual case records were reviewed. There were 19 cases of PH in 78,961 deliveries giving an incidence of 1 in 4,156 (0.02%). Of the 19 cases, 95% were delivered by caesarean section and 89% had one or more prior sections. The indications were placental bed pathology (79%), uterine atony (16%) and uterine trauma (5%). Of the 19 hysterectomies, 16 (84%) were total and a gynaecological oncologist was involved in nine (56%) of these cases. There were no maternal or fetal deaths, but a mother required an average blood transfusion of 10 units. The overall rate of PH was remarkably low compared with other studies but it is likely to increase in the future because of the strong association between increasing caesarean section rates and placental bed pathology. The potential involvement of the cervix and other pelvic structures by placental pathology means that PH in the future will be more challenging, and the hysterectomy will need to be total rather than subtotal.

Polycystic ovary syndrome and the peripheral blood white cell count

This retrospective cross-sectional study examined if the white cell count (WCC) is increased in women with polycystic ovary syndrome (PCOS) and if so, is it due to PCOS or to the associated obesity? Body mass index (BMI) was calculated and body composition was measured using bioelectrical impedance analysis. Of the 113 women studied, 36 had PCOS and 77 did not. The mean WCC was higher in the PCOS group compared with the non-PCOS group (8.9 × 109/l vs 7.4 × 109/l p = 0.002). This increase was due to a higher neutrophil count (5.6 × 109/l vs 4.3 × 109/l; p = 0.003). There was a leucocytosis (WCC >11 × 109/l) present in 19% of the PCOS group compared with 1% in the non-PCOS group (p < 0.001). The neutrophil count was abnormally high (>7.7 × 109/l) in 14% of the PCOS group compared with 4% in the non-PCOS group (p < 0.001). On regression analysis, however, the only independent variable which explained both the increased WCC and the increased neutrophil count was PCOS. We found that PCOS is associated with an increased WCC due to increased neutrophils, which supports the evidence that PCOS is associated with low-grade inflammation. The increase appears to be due to the underlying PCOS, and not to the increased adiposity associated with PCOS.

Body Mass Index and Blood Pressure Measurement during Pregnancy

Objective. The accurate measurement of blood pressure requires the use of a large cuff in subjects with a high mid-arm circumference (MAC). This prospective study examined the need for a large cuff during pregnancy and its correlation with maternal obesity. Methods. Maternal body mass index (BMI), fat mass, and MAC were measured. Results. Of 179 women studied, 15.6% were obese. With a BMI of level 1 obesity, 44% needed a large cuff and with a BMI of level 2 obesity 100% needed a large cuff. Conclusion. All women booking for antenatal care should have their MAC measured to avoid the overdiagnosis of pregnancy hypertension.

Influence of maternal glycemia on intrauterine fetal adiposity distribution after a normal oral glucose tolerance test at 28 weeks gestation.

Objective. To examine the relationship between maternal glucose levels and intrauterine fetal adiposity distribution in women with a normal oral glucose tolerance test (OGTT) at 28 weeks gestation. Study Design. We recruited 231 women with a singleton pregnancy. At 28 and 37 weeks gestation, sonographic measurements of fetal body composition were performed. Multiple regression analysis was used to study the influence of different maternal variables on fetal adiposity distribution. Results. Maternal glucose levels correlated with the fetal abdominal subcutaneous tissue measurements (r = 0.2; P = 0.014) and with birth weight (r = 0.1; P = 0.04). Maternal glucose levels did not correlate with the fetal mid-thigh muscle thickness and mid-thigh subcutaneous tissue measurements. Conclusion. We found that in nondiabetic women maternal glucose levels not only influence fetal adiposity and birth weight, but also influence the distribution of fetal adiposity. This supports previous evidence that maternal glycemia is a key determinant of intrauterine fetal programming.

Timing of screening for gestational diabetes mellitus in women with moderate and severe obesity.

Objective. We evaluated screening with a diagnostic oral glucose tolerance test earlier than 20 weeks gestation in women with moderate to severe obesity. Design. Prospective observational study. Setting. Large university teaching hospital. Population. We enrolled 100 women booking for antenatal care in the first trimester at their convenience. Methods. Height and weight were measured and body mass index calculated. Only women with a body mass index>34.9 kg/m2 were included. Women were booked for a 100 g oral glucose tolerance test before 20 weeks and, if normal, another test at 28 weeks gestation. Main outcome measures. Impaired glucose tolerance and gestational diabetes mellitus. Results. Of the 100 women given an appointment for an oral glucose tolerance test before 20 weeks gestation, 92 attended. Of these, 10 (10.8%) women had an abnormal result, with impaired glucose tolerance in five (5.4%) cases and gestational diabetes mellitus in five (5.4%) cases. Of those with a normal result at 20 weeks, 81 attended for a repeat test at 28 weeks gestation. A further four (4.9%) had impaired glucose tolerance and four (4.9%) had gestational diabetes mellitus. A total of 18 (20.5%) of the 88 women who complied with screening had an abnormal test. Conclusions. Women who have moderate/severe obesity have a one in five chance of having an abnormal diagnostic oral glucose tolerance test when screened for gestational diabetes mellitus. To optimize maternal glycemic control in pregnancy, we suggest that women with a body mass index>34.9 kg/m2 may need to be screened early in pregnancy and, if the test is normal, again at 28 weeks gestation.

Longitudinal study of aortic isthmus Doppler in appropriately grown and small-for-gestational-age fetuses with normal and abnormal umbilical artery Doppler

To establish reference ranges using longitudinal data for aortic isthmus (AoI) Doppler indices in appropriate‐for‐gestational‐age (AGA) fetuses and to document the longitudinal trends in a cohort of small‐for‐gestational‐age (SGA) fetuses with normal umbilical artery Doppler and in fetuses with intrauterine growth restriction (IUGR) and abnormal umbilical artery Doppler.

Maternal obesity and inpatient medication usage

What is already known about this subject •  Maternal obesity is associated with an increased use of healthcare resources including medication costs in an outpatient setting.

Body mass index and hypertensive disorders of pregnancy

OBJECTIVES We compared the incidence of the hypertensive disorders of pregnancy in obese women with women of a normal body mass index (BMI). STUDY DESIGN Prospective observational study in which BMI was calculated accurately early in pregnancy. Women were enrolled after a sonographic confirmation of an ongoing pregnancy. To reduce confounding variables the study was confined to white European women with a singleton pregnancy. MAIN OUTCOME MEASURES Incidence of pre-eclampsia and gestational hypertension. RESULTS In 2230 women, 16.8% were obese. Pre-eclampsia was diagnosed in 3.3% (n=74) and gestational hypertension in 3.0% (n=67). Both pre-eclampsia (p=0.01) and gestational hypertension (p<0.01) were common in obese women compared with normal weight women. Overall 13.1% of obese women developed a hypertensive disorder during pregnancy. When analysed by parity pre-eclampsia occurred in 2.1% of primigravidas and 0.3% of multigravidas. Pre-eclampsia was increased in obese multigravidas (p=0.001), but not obese primigravidas, suggesting that parity is more influential than obesity in the development of pre-eclampsia. CONCLUSIONS Obese multigravidas are more likely to develop hypertensive disorders in pregnancy and obese primigravidas are more likely to develop gestational hypertension. This is important in clinical practice because maternal weight, unlike parity, is potentially modifiable before or during pregnancy.