Kelly Kuo

Contemporary outcomes of sickle cell disease in pregnancy

BACKGROUND Data regarding pregnancy outcomes in sickle cell disease are conflicting. Previous studies are limited by small sample size, narrow geographic area, and a wide range of resource availability. OBJECTIVE The purpose of this study was to examine the association between maternal sickle cell disease and adverse pregnancy outcomes in a contemporary North American cohort. STUDY DESIGN We performed a retrospective cohort study of 2,027,323 women with singleton pregnancies delivered in California from 2005-2008. Deliveries at <24 or >42 6/7 weeks of gestation were excluded. Women with sickle cell disease were compared with control subjects. Maternal outcomes of interest included preeclampsia, preterm delivery, placental abruption, oligohydramnios, and cesarean delivery; neonatal outcomes included small for gestational age, anomalies, stillbirth, neonatal death, and infant death. RESULTS The prevalence of sickle cell disease was 0.017%. Compared with control subjects, women with sickle cell disease were more likely to have limited prenatal care (7.4 vs 3.8%; P=.001), underlying chronic hypertension (2.3% vs 1.1%; P=.038), and fetal anomalies (14.0 vs 6.4%; P<.001). The increased odds of fetal anomalies persisted after adjustment for multiple confounders (odds ratio, 1.73; 95% confidence interval, 1.26-2.38). Women with sickle cell disease also had higher odds of severe preeclampsia (odds ratio, 3.75; 95% confidence interval, 2.21-6.38), preterm delivery (odds ratio, 2.50; 95% confidence interval, 1.93-3.21), small for gestational age (odds ratio, 1.96; 95% confidence interval, 1.18-3.25), and cesarean delivery (odds ratio, 1.93; 95% confidence interval, 1.40-2.67). CONCLUSION Women with sickle cell disease are at high risk of maternal and neonatal morbidity. Low rates of fetal and neonatal death may reflect improved antenatal surveillance and management as compared with previous studies. The association between sickle cell disease and fetal anomalies warrants further investigation.

Maternal outcomes following the initiation of an institutional delayed cord clamping protocol: an observational case–control study

Abstract Objective: The objective of this study is to evaluate maternal outcomes before and after implementation of an institutional delayed cord clamping (DCC) protocol. Study design: We performed a secondary analysis of a retrospective cohort study of deliveries occurring at <34 weeks at a tertiary care center in 2013–2014. About 139 women who underwent early cord clamping were compared with 130 women delivered after DCC protocol implementation. Maternal estimated blood loss (EBL) was the primary outcome of interest. Operative times, post-Cesarean decrease in hemoglobin (Hgb), and rates of post-partum hemorrhage and transfusion were also examined in bivariate and multivariable analyses. Results: About 75% of post-guideline deliveries had actual DCC. In regression analyses, only Cesarean delivery and multifetal gestation increased EBL. No trends were identified in EBL over time. In post-hoc analysis, the study had over 80% power to detect a difference in post-partum hemorrhage rates of 20%. Conclusion: An institutional DCC protocol for deliveries <34 weeks was not associated with an identifiable increase in adverse maternal outcomes.

Maternal, fetal, and neonatal imatinib levels with treatment of chronic myeloid leukemia in pregnancy

BACKGROUND Pregnant women with chronic myeloid leukemia (CML) can be treated effectively with the tyrosine-kinase inhibitor imatinib, but data regarding fetal and neonatal exposure and safety are limited. CASE We present a patient with newly diagnosed CML in early pregnancy. Leukapheresis and interferon-α were initiated in the second trimester with limited benefit. Imatinib was subsequently started at 28 weeks of gestation with complete hematologic response within 4 weeks. No significant maternal or neonatal adverse effects were noted, but imatinib and its primary active metabolite concentrated in maternal breast milk and neonatal urine. CONCLUSION Imatinib is effective for CML in pregnancy, but caution is warranted in light of potentially unrecognized fetal and neonatal effects.

Optimal timing of delivery for women with breast cancer, according to cancer stage and hormone status: a decision-analytic model

Abstract Objective: To compare strategies for the timing of delivery in women with breast cancer and known cancer stage or hormone receptor subtype, and to determine the optimal gestational age for induction in regards to maternal-fetal outcomes. Study design: A decision-analytic model was designed comparing eight different strategies for scheduled delivery at 30, 31, 32, 33, 34, 35, 36, and 37 weeks gestation. Optimal breast cancer treatment was assumed to be delayed until after delivery. Baseline estimates of the stage- and subtype-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age. Univariate sensitivity analyses and Monte Carlo simulations were performed to test the robustness of our model. Results: For women with stage I–II breast cancer, delivery at 36 weeks yielded the highest number of overall quality-adjusted life years (QALYs), while maternal QALYs were maximized with delivery at 34 weeks. For stage III and IV disease, maternal QALYs were maximized at 31 and 30 weeks, respectively. For women with estrogen or progesterone receptor-positive, human epidermal receptor-2 negative breast cancer, both maternal QALYs and overall QALYs were maximized with delivery at 36 weeks. More aggressive biological phenotypes were similarly associated with optimal delivery at decreasing gestational age. Our model was heavily driven by the baseline probability of maternal death within 5 years, in addition to the expected progression of disease and decreases in survival rates with each week of non-treatment, and remained robust across reasonable ranges for all variables of interest. Conclusions: For women with breast cancer diagnosed during pregnancy, decisions regarding timing of delivery should take into consideration both cancer stage and hormone receptor subtype.

Optimal Timing of Delivery for Women with Hormone Receptor-Positive Breast Cancer [30E]

INTRODUCTION:Data are limited regarding the optimal management of breast cancer in pregnancy. We aimed to compare strategies for the management of estrogen or progesterone hormone receptor-positive (HR+) tumors, and to determine the optimal gestational age for induction in regards to chemotherapy st

Neonatal Birth Weight Trends: Are Newborns Getting Smaller? [136]

INTRODUCTION: Neonatal birth weight is an important composite indicator of neonatal health. We sought to examine trends in neonatal birth weight at our institution, an urban tertiary care center. METHODS: A retrospective perinatal database review was performed for all singleton term births from 2007 to 2013. Exclusion criteria included inadequate gestational age dating, multiple gestation, preterm birth, and known fetal growth restriction or anomalies. Neonates were categorized by gender and ethnicity and regression analysis performed. RESULTS: A total of 21,413 births were included. A statistically significant decrease in mean birth weight was noted for all groups over the study period with the largest decrease seen in Caucasian boys. These changes were not accounted for by maternal tobacco use, hypertension, or diabetes. CONCLUSION: Neonatal birth weights have declined, although the clinical significance of these findings is unclear; ethnic differences may deserve further investigation.