Lucy Bowyer

Vitamin D, PTH and calcium levels in pregnant women and their neonates.

Objectives  To determine the prevalence of vitamin D deficiency in pregnant women and their neonates and to examine factors associated with vitamin D deficiency.

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.

Forearm blood flow in pre-eclampsia.

Objective 1. To characterise the forearm vascular reactivity of women with pre‐eclampsia in the third trimester of pregnancy and compare it with that in normal or gestational hypertensive pregnancies. 2. To document female sex steroid (oestradiol, progesterone, oestriol and βhCG) levels in the three groups of women.

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.

Monozygotic triplets after single blastocyst transfer: Case report and literature review

A 28‐year‐old woman undertaking in vitro fertilisation had a single day five blastocyst transferred, resulting in a monozygotic triplet pregnancy. This case report illustrates the potential for multiple pregnancies even after transfer of a single embryo. A literature review regarding monozygotic triplets following use of assisted reproductive techniques reveals that an unexpectedly large proportion of these cases are associated with blastocyst transfer.

Fracture of the neck of the femur and osteomalacia in pregnancy

Case reportA 24 year old Muslim woman in full purdah, (no skinexposed in public, including veiling of the face and glovingof the hands), appeared at the antenatal clinic in a wheel-chair at term. This was her third pregnancy, havingreceived no antenatal care until consulting her generalpractitioner at 38 weeks of gestation by uncertain dates.She had had two previous vaginal deliveries, in January1999 and May 2000, both at term. Her second pregnancyhad been complicated by right-sided ‘sciatica’ in the thirdtrimester, but her obstetric and medical history was other-wise unremarkable and she took no medications apart fromiron supplements. Antenatal blood results were normal aswas an ultrasound scan. She had complained to her generalpractitioner of severe right-sided leg pain on mobilising.Doppler ultrasound examination of her legs was normal. Nofurther examination or investigation of her leg was under-taken at the antenatal clinic. The pain, which continued toconfine her to a wheelchair, was again thought to be due to‘sciatica’.At 42 weeks of gestation by a late ultrasound scan shewas admitted to the delivery suite in early labour. Herlabour progressed slowly over the following 22 hours andthe fetal head failed to engage into the pelvis. The womanagreed to a caesarean section, resulting in the delivery of ahealthy boy weighing 4285 g. On the fourth day after hercaesarean section, it was noted that the woman walked withextreme difficulty. On examination, the right quadricepsand gastrocnemius muscles were wasted and there wasweakness of the muscles of the right hip. Her reflexes werenormal and there was no loss of sensation. She had amarkedly abnormal gait. Plain X-rays of her pelvis andright hip showed a fracture of the neck of her right femur,with significant displacement. In addition, there were sub-acute healing fractures of the left superior and inferiorpubic rami, a sclerotic area of the right ischium suggestiveof an old healing fracture and generally osteopenic boneswith subcortical tunnelling and thinning of the cortex.The results of bone mineral densitometry were in keep-ing with established osteoporosis. The results of bonebiochemistry are shown in Table 1. A bone scan showedabnormal focal uptake throughout the ribs bilaterally, theintertrochanteric area of the right femur, the neck of the leftfemur medially and the distal part of the left femur, inkeeping with multiple fractures. Bone marrow biopsyperformed 16 days postnatally was normal, showing normalcellularity, a little patchy endosteal fibrosis and some boneresorption and remodelling with groups of osteoclasts.Screening for the malabsorption syndrome found a highIgG gliadin but normal IgA and endomysial antibody.A diagnosis of osteomalacia secondary to vitamin Ddeficiency was made, with superimposed osteoporosis andpossibly a component of malabsorption (the woman pre-ferred not to undergo further gastrointestinal investi-gations). Her vitamin D deficiency was thought to be acombination of lack of exposure to sunlight (she had beenwearing full purdah since arrival in Australia four yearspreviously), poor nutrition and possible malabsorption. Shedenied the possibility of physical abuse when questionedthrough a female interpreter by a female doctor without herhusband present, and there were no marks on her body tosuggest this alternative diagnosis.Closed reduction of the right hip fracture and insertion ofthree cannulated screws was performed by the orthopaedicteam. The woman was discharged 23 days postnatallypartially weight-bearing on her left leg (the bone scansuggested incipient left-sided femoral fracture) and stillnon-weight-bearing on her right leg. She was given600,000 units of vitamin D intramuscularly before herdischarge. She went home taking ergocalciferol 1000 Utwice daily and calcium 600 mg twice daily. Her babyshowed no signs of neonatal hypocalcaemia and hadnormal alkaline phosphatase but low vitamin D levels.DiscussionAlthough symptomatic osteomalacia in pregnancy hasbeen reported previously, we believe this is the first caseof fractured neck of femur in pregnancy secondary toosteomalacia. The fetus at term contains approximately30 g of calcium and lactating women excrete approxi-mately 210 mg/day of calcium in breast milk

SOMANZ guidelines for the investigation and management sepsis in pregnancy

SOMANZ (Society of Obstetric Medicine Australia and New Zealand) has written a guideline to provide evidence‐based guidance for the investigation and care of women with sepsis in pregnancy or the postpartum period. The guideline is evidence‐based and incorporates recent changes in the definition of sepsis. The etiology, investigation and treatment of bacterial, viral and non‐infective causes of sepsis are discussed. Obstetric considerations relevant to anaesthetic and intensive care treatment in sepsis are also addressed. A multi‐disciplinary group of clinicians with experience in all aspects of the care of pregnant women have contributed to the development of the guidelines. This is an executive summary of the guidelines.

Successful vaginal birth after three previous Caesarean sections with no prior labour

A 36-year-old woman consulted for a second opinion at 32 weeks’ gestation in her fourth pregnancy. The woman wished to have a vaginal birth, having previously had three lower segment Caesarean sections. Her pregnancy had been uncomplicated with no vaginal bleeding; she was fit and well with a low body mass index. Her first baby (male 3.62 kg) was delivered in South Africa in 1994 by elective Caesarean section with an ante-partum diagnosis of ‘cephalo-pelvic disproportion’. Her second baby (female 3.24 kg) was delivered by elective Caesarean section, again in South Africa, in 1996 for the indication of previous Caesarean section. In 1998 she and her family moved to the UK, she was keen to attempt vaginal birth and this was agreed provided that she laboured spontaneously before 42 weeks’ gestation. At 42 weeks she had a third elective Caesarean section (female infant, 3.24 kg), as spontaneous labour had not occurred. The patient was very unhappy with the conduct of her previous deliveries. On each occasion the epidural had been difficult to insert, a spinal tap had occurred with the first baby and she felt bereft that she was unable to hold her babies (beyond the brief standard initial contact) and keep them with her. The consultation with her involved a review of published reports examining births after two or more previous Caesarean sections. It was obvious that she and her husband were already well informed with regard to the likely success of vaginal delivery and the possible uterine rupture rates. The opinion offered was a 60% chance of vaginal birth and a 3% risk of scar rupture with subsequent serious consequences. It was agreed that, after 6 h of active labour, if progress was poor then a Caesarean section would be advised. The risk of placenta praevia and percreta was discussed, and ultrasound revealed a posterior placenta well clear of the lower segment. As they wished to accept the risks involved, a vaginal birth after three previous Caesarean sections was planned at St. George Hospital, New South Wales, Australia. It was agreed that continuous fetal monitoring would be carried out throughout labour, if after 6 h of active labour delivery was not imminent then Caesarean section would be advised. At the 37-week visit the fetal lie was oblique; subsequently the lie became longitudinal with a cephalic, but unengaged, presentation at term. As she had been having short-lived contractions irregularly through the night and was fearful that intervention would be suggested she did not attend for her 41-week visit. However, she was persuaded to attend for an antenatal 42-week consultation. She had been having contractions overnight with only mild pain and felt well. The cervix was posterior, soft, 50% effaced and closed, the fetal vertex was 2 cm above the ischial spines, fetal movements and heart rate were normal. The increased risk of unexpected stillbirth as gestation prolongs was discussed, and she declined fetal ultrasound or cardiotocography. The following day at 42 weeks and 1 day gestation, she arrived in hospital in the evening, having had contractions that had become more painful and more regular throughout the day. On examination the cervix was 8 cm dilated, fully effaced and the fetal head at the ischial spines. She proceeded to have a normal vaginal birth 90 min later with a right medio-lateral episiotomy. A live male infant was born in excellent condition, weighing 3.565 kg. She and her husband were delighted with the outcome and she was discharged home on the early discharge program the following day.

Surprisingly good outcome in antenatal diagnosis of severe hydrocephalus related to CCDC88C deficiency

Non-syndromic congenital hydrocephalus is aetiologically diverse and while a genetic cause is frequently suspected, it often cannot be confirmed. The most common genetic cause is L1CAM-related X-linked hydrocephalus and that explains only 5%-10% of all male cases. This underlines a current limitation in our understanding of the genetic burden of non-syndromic congenital hydrocephalus, especially for those cases with likely autosomal recessive inheritance. Additionally, the prognosis for most cases of severe congenital hydrocephalus is poor, with most of the surviving infants displaying significant intellectual impairment despite surgical intervention. It is for this reason that couples with an antenatal diagnosis of severe hydrocephalus are given the option, and may opt, for termination of the pregnancy. We present two families with CCDC88C-related recessive congenital hydrocephalus with children who had severe hydrocephalus. Those individuals who were shunted within the first few weeks of life, who did not require multiple surgical revisions, and who had a more distal truncating variant of the CCDC88C gene met their early childhood developmental milestones in some cases. This suggests that children with CCDC88C-related autosomal recessive hydrocephalus can have normal developmental outcomes under certain circumstances. We recommend CCDC88C analysis in cases of severe non-syndromic congenital hydrocephalus, especially when aqueduct stenosis with or without a medial diverticulum is seen, in order to aid prognosis discussion.

Maternal hemodynamics influence fetal hemodynamics in normal and hypertensive pregnancy.

OBJECTIVES This observational case-control study aims to test whether there is a relationship between maternal systemic hemodynamics, maternal renin-angiotensin system and fetal hemodynamics in normal and hypertensive pregnancy. STUDY DESIGN Four groups of non-pregnant women (n=18), pregnant controls (n=25), women with gestational hypertension (n=21) and preeclampsia (n=10) were included. MAIN OUTCOME MEASURES Maternal echocardiography parameters, plasma renin and aldosterone were correlated with fetal Doppler parameters in third trimester pregnancy. RESULTS Higher maternal mean arterial pressure and total peripheral vascular resistance were associated with lower fetal middle cerebral artery pulsatility index (PI) (r=-.51, p<0.01 and r=-.49, p<0.01, respectively); mean arterial pressure correlated negatively with ductus venosus PI (r=-.35, p=0.01); higher maternal plasma aldosterone levels were associated with lower maternal uterine artery resistance (r=-0.33, p=0.03). CONCLUSIONS It seems that maternal hemodynamics influence fetal hemodynamics with protective adaptation in fetal cerebral and ductus venosus blood flow observed as maternal blood pressure and vascular resistance increase.