Kofi Amankwah

Risk and Predictors for Pregnancy-Related Complications in Women With Heart Disease

BACKGROUND The physiological changes of pregnancy can result in cardiovascular complications in the mother, which in turn may have fetal implications. Prior studies have focused on specific cardiac lesions or identified univariate predictors. There is a need to refine the risk stratification of women with heart disease so they can receive appropriate obstetrical counseling and care. METHODS AND RESULTS We examined the outcomes of 221 women with heart disease who underwent 276 pregnancies and received their obstetrical care at three Toronto hospitals from 1986 through 1994. Those who underwent therapeutic abortions were excluded. Among the study participants, there were 24 miscarriages and 252 completed pregnancies (pregnancies not ending in miscarriage). Maternal heart failure, arrhythmia, or stroke occurred in 45 completed pregnancies (18%). There were no maternal deaths. Poor maternal functional class or cyanosis, myocardial dysfunction, left heart obstruction, prior arrhythmia, and prior cardiac events were predictive of maternal cardiac complications. These predictors were incorporated into a point score that can be used to estimate the probability of a cardiac complication in the mother. The rate of cardiac complications for a patient with 0, 1, and >1 of the above factors was 3%, 30%, and 66%, respectively. Neonatal complications occurred in 42 completed pregnancies (17%). Neonatal events included death (2), respiratory distress syndrome (16), intraventricular hemorrhage (2), premature birth (35), and small-for-gestational-age birth weight (14). Poor maternal functional class or cyanosis was predictive of neonatal events. CONCLUSIONS Despite low maternal and neonatal mortality, pregnancy in women with heart disease is associated with significant cardiac and neonatal morbidity. The probability of maternal cardiac or neonatal events can be predicted from baseline characteristics of the mother.

Gestational diabetes diagnostic criteria: Long-term maternal follow-up

OBJECTIVE The purpose of this study was to determine if the risk of having diabetes later in life was different in those who were gestational diabetic by Coustan criteria and not by National Diabetes Data Group criteria and those who are gestational diabetic only by National Diabetes Data Group criteria. STUDY DESIGN Between 1988 and 1990, 331 patients from the Springfield area who were diagnosed as gestational diabetic by either criteria since 1975 were examined for the development of diabetes by history or by 2-hour, 75 gm glucose tolerance test. National Diabetes Data Group criteria were used to determine normality or diabetic abnormality. Variables associated with diabetes were obtained. The data were analyzed using three groups: (1) gestational diabetic by National Diabetes Data Group criteria, (2) gestational diabetic by Coustans criteria only, and (3) both groups 1 and 2. RESULTS Group 1 had 190 (57.4%) and group 2 had 141 patients (42.6%), of which 25.3% and 25.5% had diabetic abnormality, respectively. Variables predictive for the development of diabetic abnormality were glucose tolerance test fasting value, number of gestational diabetic pregnancies, time to follow-up, and prepregnancy weight index. There were no differences in these variables between the normal patients or those with diabetic abnormality in groups 1 and 2. CONCLUSION Because Coustan criteria classify an additional 68.9% patients who have the same risk and risk factors for later development of diabetic abnormality and pregnancy complications compared with patients who are gestational diabetic by National Diabetes Data Group criteria, the criteria of Carpenter and Coustan should be adopted as the standard for diagnosing gestational diabetes.

The effect of indomethacin tocolysis in preterm labour on perinatal outcome: a randomised placebo-controlled trial

Objective To determine whether indomethacin tocolysis in preterm labour is associated with a better perinatal outcome than placebo.

Effect of antenatal corticosteroids on fetal growth and gestational age at birth

OBJECTIVE: To estimate the effect of multiple courses of antenatal corticosteroids on neonatal size, controlling for gestational age at birth and other confounders, and to determine whether there was a dose–response relationship between number of courses of antenatal corticosteroids and neonatal size. METHODS: This is a secondary analysis of the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study, a double-blind randomized controlled trial of single compared with multiple courses of antenatal corticosteroids in women at risk for preterm birth and in which fetuses administered multiple courses of antenatal corticosteroids weighed less, were shorter, and had smaller head circumferences at birth. All women (n=1,858) and children (n=2,304) enrolled in the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study were included in the current analysis. Multiple linear regression analyses were undertaken. RESULTS: Compared with placebo, neonates in the antenatal corticosteroids group were born earlier (estimated difference and confidence interval [CI]: −0.428 weeks, CI −0.10264 to −0.75336; P=.01). Controlling for gestational age at birth and confounding factors, multiple courses of antenatal corticosteroids were associated with a decrease in birth weight (−33.50 g, CI −66.27120 to −0.72880; P=.045), length (−0.339 cm, CI −0.6212 to −0.05676]; P=.019), and head circumference (−0.296 cm, −0.45672 to −0.13528; P<.001). For each additional course of antenatal corticosteroids, there was a trend toward an incremental decrease in birth weight, length, and head circumference. CONCLUSION: Fetuses exposed to multiple courses of antenatal corticosteroids were smaller at birth. The reduction in size was partially attributed to being born at an earlier gestational age but also was attributed to decreased fetal growth. Finally, a dose–response relationship exists between the number of corticosteroid courses and a decrease in fetal growth. The long-term effect of these findings is unknown. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00187382. LEVEL OF EVIDENCE: II

Hemolytic anemia and pyruvate kinase deficiency in pregnancy.

&NA; Hemolytic anemia due to deficiency of erythrocytic pyruvate kinase is a rare autosomal recessive disorder. Pregnancy complicated by pyruvate kinase deficiency is rare; there are only 8 reported cases in the literature. A case is described that was characterized by increased hemolysis during pregnancy, requiring blood transfusions before and after delivery, and complicated by severe preeclampsia at term. Fetal and maternal outcome was successful. Increased hemolysis and favorable perinatal outcome occurred in all 8 reported cases.

The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial

Background: The Term Breech Trial compared the safety of planned cesarean and planned vaginal birth for breech presentations at term. The combined outcome of perinatal or neonatal death and serious neonatal morbidity was found to be significantly lower among babies delivered by planned cesarean section. In this study we conducted a cost analysis of the 2 approaches to breech presentations at delivery. Methods: We used a third-party–payer (i.e., Ministry of Health) perspective. We included all costs for physician services and all hospital-related costs incurred by both the mother and the infant. We collected health care utilization and outcomes for all study participants during the trial. We used only the utilization data from countries with low national rates of perinatal death (≤ 20/1000). Seven hospitals across Canada (4 teaching and 3 community centres) were selected for unit cost calculations. Results: The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth (

The Relationship of von Willebrand Factor Binding to Activated Platelets from Healthy Neonates and Adults

7165 v.

Gabapentin use in hyperemesis gravidarum: a pilot study.

8042 per mother and infant; mean difference –

Does endothelin-1 reduce superior mesenteric artery blood flow velocity in preterm neonates?

877, 95% credible interval –

Multiple Courses of Antenatal Corticosteroids for Preterm Birth

1286 to –