Michèle Mahone

Gestational Diabetes Insipidus: A Review of an Underdiagnosed Condition

OBJECTIVE To review the etiology, diagnosis, and management of diabetes insipidus during pregnancy. DATA SOURCES A search of the literature was performed in PubMed using key word searching and citation snowballing to identify articles published in English between January 1, 1980, and December 31, 2008, on the subject of diabetes insipidus during pregnancy. Once the articles were identified, a thorough review of all results was conducted. Results and conclusions were compiled and summarized. STUDY SELECTION We reviewed 50 studies selected using the following key words: diabetes insipidus, pregnancy, arginine vasopressin, vasopressinase. CONCLUSION Gestational diabetes insipidus is underdiagnosed because polyuria is often considered normal during pregnancy. Clinicians caring for pregnant women should consider screening for gestational diabetes insipidus, because it could be associated with serious underlying pathology.

Hepatic rupture in hemolysis, elevated liver enzymes, low platelets syndrome.

OBJECTIVE: Rupture of hepatic hematoma associated with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome is a catastrophic complication of pregnancy. Maternal and fetal mortality rates are still high despite advances in diagnosis and treatment. We aimed to present our experience at two referral centers for hepatic disease and to compare it with cases from the literature. METHODS: We reviewed nine cases that occurred over the past 6 years in our centers and made an extensive literature review covering the past 10 years. We reviewed and compared multiple outcomes for all these cases. RESULTS: The median maternal age of our patients was 29 years (interquartile range 27–32). Embolization treatment was used with seven of nine (78%) of our patients compared with 5 of 88 (6%) in the literature (P<.001). Our maternal and fetal mortality rates were 0% (95% confidence interval [CI] 0–34%) and 30% (95% CI 7–65%), respectively, compared with 17% (95% CI 10–26%) and 38% (95% CI 31–52%]) from our review of the literature from 2000 to 2010. CONCLUSION: The use of hepatic artery embolization to address hepatic rupture associated with HELLP syndrome may help minimize morbidity and maternal mortality. LEVEL OF EVIDENCE: III

The Effects of Ursodeoxycholic Acid Treatment for Intrahepatic Cholestasis of Pregnancy on Maternal and Fetal Outcomes: A Meta-Analysis Including Non-Randomized Studies

OBJECTIVE The benefits of ursodeoxycholic acid (UDCA) use for treating intra-hepatic cholestasis of pregnancy (ICP) remain uncertain. A 2010 Cochrane Review of randomized control trials was unable to recommend either for or against the use of UDCA in treating ICP. We conducted a meta-analysis of the literature, including both non-randomized studies (NRSs) and RCTs. The objective of the study was to determine if patients included in NRSs were comparable to those in RCTs, and to determine whether the inclusion of NRSs could strengthen the available evidence and guide clinical practice on UDCA use in women with ICP. DATA SOURCES We searched Medline (Ovid), Embase (Ovid), EMB Reviews, Cinahl (Ebsco), and Web of Knowledge (Thomson Reuters) for articles published from 1966 to June 2012. STUDY SELECTION We included all eligible RCTs of UDCA versus placebo or other treatments, and all NRSs comparing UDCA with any other treatment in women with ICP. DATA SYNTHESIS We included 11 RCTs (n = 625 pregnancies) and six NRSs (n = 211 pregnancies). The women included in RCTs and NRSs were comparable, but study quality was poorer for NRSs. Overall, women treated with UDCA had decreased pruritus in 73% of RCTs and in 100% of NRSs with available data. Liver function tests were improved in 82% of RCTs and in 100% of NRSs with available data. UDCA use did not affect the Caesarean section rate, but was associated with less prematurity, less use of neonatal intensive care units (data available in only 3/17 studies), and trends towards increased birth weight and decreased meconium staining. There were 0/356 stillbirths with UDCA and 3/399 stillbirths with comparator. CONCLUSION UDCA treatment should be recommended for women with ICP to reduce adverse maternal and fetal outcomes.

Pregnancy-Related Venous Thromboembolism Risk in Asymptomatic Women With Antithrombin Deficiency: A Systematic Review.

OBJECTIVE: To evaluate the risk of pregnancy-associated venous thromboembolism in women with asymptomatic antithrombin deficiency. DATA SOURCES: The search was performed on MEDLINE (Ovid and PubMed databases) for the period 1966 to June 2012 and ClinicalTrials.gov as of December 15, 2015. METHODS OF STUDY SELECTION: A systematic review including randomized controlled trials, cohort studies, and case–control studies was conducted. Selection criteria included objectively diagnosed venous thromboembolism or venous thromboembolism treated with 3 months of anticoagulation before the availability of objective testing. The study population consisted of pregnant women with asymptomatic antithrombin deficiency. TABULATION, INTEGRATION, AND RESULTS: Seven publications were included in the review. No randomized controlled trials were identified. The best available data consist of three retrospective cohort studies and four case–control studies. Pooled results from case–control studies yielded an estimated odds ratio for venous thromboembolism of 6.09 (95% confidence interval 1.58–23.43). No pooled estimates could be obtained for cohort studies. Data on use of thromboprophylaxis were scarce. CONCLUSION: Despite the small number of patients included, and the variation in study designs, pooled results from case–control studies show a significant association between asymptomatic antithrombin deficiency and pregnancy-associated venous thromboembolism. Thromboprophylaxis during pregnancy and postpartum should be considered in these women.

Are There Benefits for Gestational Diabetes Mellitus in Treating Lower Levels of Hyperglycemia Than Standard Recommendations

OBJECTIVES The new International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommendations for diagnosis of gestational diabetes mellitus (GDM) are generating discussion regarding their universal adoption. Our centre is currently using stricter GDM diagnostic criteria than those proposed by the IADPSG. Evaluation of complication rates and their predictors in our cohort may provide insight for the care of this high-risk population. Therefore, we determined complication rates and identified antepartum maternal predictors of adverse outcomes in our cohort with mild GDM. METHODS A retrospective cohort study was performed between 2005 and 2011. It included women with and without GDM, which was diagnosed if fasting plasma glucose levels were 5.0 or above or 2-hour post 75 gram oral glucose tolerance test (OGTT) were 7.8 mmol/L or higher. RESULTS A total of 3712 women, with and without diabetes, were included. Rates of macrosomia and pre-eclampsia were significantly higher in the group with GDM but were lower than the rates usually reported. Macrosomia, the need for insulin therapy or caesarean section and postpartum glucose intolerance predictors included prepregnancy body mass index, excessive gestational weight gain and OGTT screening results, although no specific threshold was found. CONCLUSIONS This study provides insight into GDM-related complications rates and the benefits of intervention in a large cohort of women with levels of hyperglycemia lower than those currently recommended for diagnosis of GDM. These findings suggest a continuous association between adverse outcomes and maternal hyperglycemia and highlight the important role of maternal risk factors other than glycemic results in the development of pregnancy-related complications. Milder forms of hyperglycemia that would not be identified by IADPSG guidelines may benefit from treatment.

Pituitary apoplexy in pregnancy: A case series and literature review

Background Severe headache during pregnancy is a challenging condition that may rarely imply endocrine disturbances. Rapid recognition of pituitary apoplexy is needed to improve pregnancy outcome. Objective To review and compare maternal and fetal outcomes after pituitary apoplexy. Methods Four cases of pituitary apoplexy during pregnancy in our centre are reported and literature review covering the past 54 years was performed. Results In the four cases presented and the 33 reported in the literature, most women presented with severe headaches and systemic symptoms. Overall, 42% were treated surgically, 31% received bromocriptine or cabergoline and 61% were given hormone replacement. No major obstetrical complication was reported and all babies were healthy. Conclusion Pituitary apoplexy is a rare cause of sudden and severe headache during pregnancy. Rapid identification of this condition with potentially associated endocrine disturbances is important to ensure maternal and fetal well-being. A multidisciplinary team approach seems to reduce morbidity and mortality.

Medical Problems in Pregnant Women

The American College of Chest Physicians (ACCP) published its latest (9th edition) guidelines in February 2012. This document is a valuable reference for all clinicians. In the current article, through the analysis of three clinical cases, the authors review, describe, and analyze the most significant new information from the chapter “VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy”: (1) strategies for clinicians facing the prescription of a new drug during pregnancy with little available data; (2) recommendations about indications of thromboprophylaxis for asymptomatic thrombophilias; and (3) thrombophilia screening and secondary prevention for placental complications.

A 30-year-old pregnant patient with massive haemoptysis and influenza A: Atypical presentation of a common pathogen

A 30-year-old woman presented at 19 weeks of gestation with symptoms of sore throat, rhinorrhea and haemoptysis that progressed to massive haemoptysis. Her medical history included asthma and a history of smoking prior to pregnancy. Investigations revealed no obvious cause of bleeding. Right lower lobe lobectomy was performed, given the suspicion of a lesion within the intermediate bronchus. The patient developed adult respiratory distress syndrome around 36 h postoperatively. Polymerase chain reaction testing on bronchoalveolar lavage samples was positive for influenza A. Therapy with oseltamivir was initiated. She was discharged two weeks later. This is a rare case of a severe complication from seasonal interpandemic influenza during pregnancy, which underscores the importance of immunization for pregnant women.