Karin Lust

Pregnancy outcomes in women of very advanced maternal age

Objective:  To assess outcomes for pregnancies progressing beyond 20 weeks’ gestation in women of very advanced maternal age.

The SOMANZ Guidelines for the Management of Hypertensive Disorders of Pregnancy 2014

Accurate blood pressure measurement is important. Attention should be paid to: • Correct posture • Cuff size • DeviceMercury sphygmomanometers remain the gold standard Self-initiated and automated blood pressure monitors may have wide intra-individual error, and their accuracy may be further compromised in preeclamptic women. Aneroid sphygmomanometers may be used but require regular recalibration to ensure accurate measurements. ABPM may help identify women with white coat hypertension.

Overweight and obesity knowledge prior to pregnancy: A survey study

BackgroundOverweight and obesity are associated with increased risk for pregnancy complications. Knowledge about increased risks in overweight and obese women could contribute to successful prevention strategies and the aim of this study is to assess current levels of knowledge in a pregnant population.MethodsCross sectional survey of 412 consecutive unselected women in early pregnancy in Brisbane, Australia: 255 public women attending their first antenatal clinic visit and 157 women at private maternal fetal medicine clinics undergoing a routine ultrasound evaluation prior to 20 weeks gestation. The cohort was stratified according to pre pregnancy BMI (< 25.0 or ≥ 25.0). The main outcome measure was knowledge regarding the risks of overweight and obesity in pregnancy.ResultsOver 75% of respondents identified that obese women have an increased risk of overall complications, including gestational diabetes and hypertensive disorders of pregnancy compared to women of normal weight. More than 60% of women asserted that obesity would increase the risk of caesarean section and less than half identified an increased risk of adverse neonatal outcomes. Women were less likely to know about neonatal complications (19.7% did not know about the effect of obesity on these) than maternal complications (7.4%). Knowledge was similar amongst women recruited at the public hospital and those recruited whilst attending for an ultrasound scan at a private clinic. For most areas they were also similar between women of lower and higher BMI, but women with BMI < 25.0 were less likely to know that obesity was associated with increased rate of Caesarean section than those with higher BMI (16.8% versus 4.5%, P < 0.001). Higher educational status was associated with more knowledge of the risks of overweight and obesity in pregnancy.ConclusionsMany women correctly identify that overweight and obesity increases the overall risk of complications of pregnancy and childbirth. The increased risks of maternal complications associated with being obese are better known than the increased risk of neonatal complications. Maternal education status is a main determinant of the extent of knowledge and this should be considered when designing education campaigns.

SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014.

This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.

Determinants of Maternal Triglycerides in Women With Gestational Diabetes Mellitus in the Metformin in Gestational Diabetes (MiG) Study

OBJECTIVE Factors associated with increasing maternal triglyceride concentrations in late pregnancy include gestational age, obesity, preeclampsia, and altered glucose metabolism. In a subgroup of women in the Metformin in Gestational Diabetes (MiG) trial, maternal plasma triglycerides increased more between enrollment (30 weeks) and 36 weeks in those treated with metformin compared with insulin. The aim of this study was to explain this finding by examining factors potentially related to triglycerides in these women. RESEARCH DESIGN AND METHODS Of the 733 women randomized to metformin or insulin in the MiG trial, 432 (219 metformin and 213 insulin) had fasting plasma triglycerides measured at enrollment and at 36 weeks. Factors associated with maternal triglycerides were assessed using general linear modeling. RESULTS Mean plasma triglyceride concentrations were 2.43 (95% CI 2.35–2.51) mmol/L at enrollment. Triglycerides were higher at 36 weeks in women randomized to metformin (2.94 [2.80–3.08] mmol/L; +23.13% [18.72–27.53%]) than insulin (2.65 [2.54–2.77] mmol/L, P = 0.002; +14.36% [10.91–17.82%], P = 0.002). At 36 weeks, triglycerides were associated with HbA1c (P = 0.03), ethnicity (P = 0.001), and treatment allocation (P = 0.005). In insulin-treated women, 36-week triglycerides were associated with 36-week HbA1c (P = 0.02), and in metformin-treated women, they were related to ethnicity. CONCLUSIONS At 36 weeks, maternal triglycerides were related to glucose control in women treated with insulin and ethnicity in women treated with metformin. Whether there are ethnicity-related dietary changes or differences in metformin response that alter the relationship between glucose control and triglycerides requires further study.

Sheehan's syndrome ‐ acute presentation with hyponatremia and headache

Sheehan’s syndrome is rare in modern obstetric practice. We present the case of a woman who developed hypovolaemic shock and disseminated intravascular coagulation following a precipitate spontaneous vaginal delivery The patient subsequently developed headaches, hyponatraemia and failure to lactate and was diagnosed with acute Sheehan’s syndrome. Few previous studies document the acute assessment of anterior pituitary function and pituitary magnetic resonance imaging (MRI). These are presented in this case along with a discussion on the atypical acute presentation and differential diagnosis of Sheehan’s syndrome.

Use of a retrievable inferior vena cava filter in term pregnancy: Case report and review of literature

Venous thromboembolism is a significant cause of morbidity and mortality in obstetrics. Management with anticoagulation can be problematic, especially peripartum. We report the successful placement and retrieval of an inferior vena cava filter as prophylaxis for peripartum pulmonary embolism in a woman with a large, proximal, deep venous thrombosis at term.

Insulin requirements in late pregnancy in women with type 1 diabetes mellitus: A retrospective review

UNLABELLED Pregnancy in women with type 1 diabetes mellitus (T1DM) is generally associated with increased insulin requirements. AIMS To determine the frequency and significance of declining insulin requirements in late gestation in women with T1DM. METHODS We conducted a retrospective review of 54 women seen at our institution from 2006 to 2010 with a diagnosis of T1DM pre-pregnancy and presentation for antenatal care prior to 28 weeks. Information was collected regarding patient demographics, insulin dose and pregnancy outcome. A 15% difference in weight-adjusted basal insulin from 30 weeks gestation to delivery was considered significant. RESULTS Five women (9.3%) had a fall of 15% or more and 23 (42.5%) had a rise of 15% or more rise in insulin requirements. There were fewer neonatal intensive care admissions but more infants with an APGAR <8 at 5 min in women with a fall in insulin requirements. These differences were not evident when the data were re-analysed by quartiles of change. CONCLUSIONS In most women with T1DM, insulin requirements show little change from 30 weeks gestation until delivery. Almost 10% of women had a significant fall in insulin requirements which did not correlate with adverse neonatal outcome. These results require validation in a larger, prospective trial.

Termination of pregnancy for maternal medical indications: failings in delivery of contraceptive advice?

Background:  The majority of therapeutic terminations of pregnancy occur for maternal psychological, social or fetal reasons. Available data on maternal medical indications, rather than social, are sparse.

Routine screening for vitamin D deficiency in early pregnancy

TO THE EDITOR: We wish to report Queensland data regarding vitamin D levels during pregnancy, to contribute to the debate on screening during pregnancy raised in Lau and colleagues’ article1 and Ebeling’s accompanying editorial.2 In 2009, we measured serum 25hydroxyvitamin D (25[OH]D) levels, using a DiaSorin radioimmunoassay (DiaSorin, Stillwater, Minn, USA), in 75 women who attended general antenatal clinics at the Royal Brisbane and Women’s Hospital (RBWH) and Mater Mothers’ Hospital. Both institutions’ Human Research Ethics Committees approved the study. Participants gave written consent. The RBWH Private Practice Fund covered pathology expenses. Fifty-seven of the 75 women were white; the remainder were Asian (five), Indian Subcontinental (seven), Polynesian (four), Middle Eastern (one) and black African (one). Mean age was 28.6 years (SD, 5.4 years), mean gestational age was 28.7 weeks (SD, 2.7 weeks) and mean body mass index was 26.4 kg/m2 (SD, 5.5 kg/m2). Median serum 25(OH)D level was 92 nmol/L (interquartile range, 74– 118 nmol/L). Using cut-offs of < 25 nmol/L for deficiency and < 50 nmol/L for insufficiency, two women were vitamin D deficient (one was Middle Eastern and one was South-East Asian) and five women were vitamin D insufficient (three were white, with lowest serum 25[OH]D level of 40 nmol/L, and two were Indian Subcontinental). The result of a Fisher exact test suggested an association with ethnicity (P = 0.01). A χ2 value of 21.36 (P < 0.001) confirmed that the proportions of deficiency and insufficiency in our study population were significantly different to those of Lau et al’s study population. The majority of serum samples (40) were obtained in winter, followed by spring (21), summer (10) and autumn (three). Six of the seven results of deficiency and insufficiency were from samples obtained in winter; the other was from a sample obtained in September. Excluding autumn, categorical and continuous analyses showed borderline significant vari-ation of 25(OH)D level by season (Mann–Whitney U test [P = 0.08] and Kruskal–Wallis test [P = 0.08], respectively). Several factors may account for the difference in vitamin D deficiency and insufficiency prevalence between our study and that of Lau et al. The most obvious is the “Sunshine State” factor, because several studies in southern states have reported higher prevalence of vitamin D insufficiency than in our study.3-5 In Lau et al’s study, a large proportion of women were at high risk of vitamin D deficiency (only 19% were white) and the women were recruited from a gestational diabetes mellitus clinic. Care should be taken in extrapolating such findings to the wider population. Although our study was not population based, it included a majority white and healthy general obstetric population, rather than sampling at a clinic where women are at high risk of vitamin D insufficiency. We are not asserting that gestational vitamin D levels are unimportant. The increasing incidence of rickets in Australia,2 along with other potential hazards, dictate that increased awareness is mandatory. However, as opposed to routine screening in all pregnancies, our data suggest that local assessment of vitamin D status and demographic risk factors (in gestational diabetes mellitus and general obstetric populations) should be the priority.