Stephen J. Bacak

Liver Failure in Pregnancy.

Acute liver failure is a rare but life-threatening medical emergency in pregnancy whose true incidence remains unknown. Many cases of acute liver failure are caused by pregnancy-related conditions such as acute fatty liver of pregnancy and HELLP syndrome. However, acute deterioration in liver function can also be caused by drug overdose, viral infections, and an exacerbation of underlying chronic liver disease. This article provides an overview of the normal liver changes that occur during pregnancy, and summarizes the most common conditions and general management strategies of liver failure during pregnancy.

Timing of induction of labor

Determining the optimal timing for induction of labor is critical in minimizing the risks to maternal and fetal health. While data are available to guide us in some clinical situations, such as hypertension and diabetes, many gaps in knowledge still exist in others, including cholestasis of pregnancy, fetal anomalies, and placental abruption. This review of the currently available literature assesses the risks and benefits of preterm and early term induction in a wide variety of maternal and fetal conditions.

Limitations of Aneuploidy and Anomaly Detection in the Obese Patient

Obesity is a worldwide epidemic and can have a profound effect on pregnancy risks. Obese patients tend to be older and are at increased risk for structural fetal anomalies and aneuploidy, making screening options critically important for these women. Failure rates for first-trimester nuchal translucency (NT) screening increase with obesity, while the ability to detect soft-markers declines, limiting ultrasound-based screening options. Obesity also decreases the chances of completing the anatomy survey and increases the residual risk of undetected anomalies. Additionally, non-invasive prenatal testing (NIPT) is less likely to provide an informative result in obese patients. Understanding the limitations and diagnostic accuracy of aneuploidy and anomaly screening in obese patients can help guide clinicians in counseling patients on the screening options.

Loeys-Dietz syndrome in pregnancy

Abstract Loeys-Dietz syndrome results from mutations in genes encoding the transforming growth factor-β receptor. Women with similar syndromes are at risk of obstetrical complications, including vessel and uterine rupture during labor. There are few reports regarding the safety of pregnancy in women with Loeys-Dietz syndrome, and the available literature recommends early cesarean delivery. We report a case of a successful vaginal delivery at 36 weeks of gestation in a primigravid woman. Prenatal imaging revealed no vascular abnormalities and echocardiogram demonstrated normal cardiac anatomy. Her pregnancy and delivery were uneventful, and the baby was also found to have the mutation on postnatal molecular testing. In a low-risk individual, vaginal delivery at term may be considered a reasonable approach in this group of women.

Predictors of anemia and iron status at birth in neonates born to women carrying multiple fetuses

BackgroundIron (Fe) status of neonates born to women carrying multiple fetuses might be compromised as a consequence of the high prevalence of maternal Fe deficiency and anemia coupled with an increased risk of preterm birth. This study aimed to characterize and identify determinants of anemia in this neonatal population.MethodsUmbilical cord blood obtained from 183 neonates was utilized to assess hemoglobin (Hb), ferritin (SF), soluble transferrin receptor (sTfR), hepcidin, serum Fe, erythropoietin, folate, vitamin B-12, C-reactive protein, and interleukin-6. Associations with maternal Fe status were explored.ResultsCord Hb or SF did not change significantly as a function of gestational age at birth (25–38 wks). Neonates born to women who were obese prior to pregnancy or smoked cigarettes during pregnancy had a 4–5-fold greater odds of anemia at birth. Cord sTfR was the strongest indicator of cord Hb (P < 0.0001), and it was significantly associated with maternal sTfR at mid-gestation (P = 0.01) and delivery (P = 0.002). Cord Fe indicators were significantly associated with cord hepcidin, but not maternal hepcidin.ConclusionScreening for Fe status in neonates born to women carrying multiple fetuses is warranted, especially for those born to smokers or to women who are obese at entry into pregnancy.

Association Between Insurance and Adequacy of Prenatal Care [257]

INTRODUCTION: Obese women and Medicaid recipients have an increased risk of poor pregnancy outcomes, which has been thought to be the result of inadequate prenatal care. However, our prior work demonstrated that maternal obesity is associated with an improved adequacy of prenatal care in our population. Although obesity was associated with increased use of ultrasound services, this alone did not explain the improvement in prenatal care adequacy associated with obesity. We sought to further examine whether payer status influences prenatal care adequacy. METHODS: From a University of Rochester database of deliveries from January 2009 to December 2011, participants were categorized by body mass index (BMI, calculated as weight (kg)/[height (m)]2) as normal weight (BMI 18.5–24.9), overweight (BMI 25–29.9), and obese (BMI 30, subdivided as class I, II, III). Prenatal care adequacy was evaluated using the Kotelchuck Index. Payer status was defined as private, Medicaid, and other (tricare, self-pay). &khgr;2 was used for univariate comparisons and logistic regression for multivariable testing. RESULTS: Of 7,090 deliveries, inadequate prenatal care was more common in both Medicaid (32.7%; odds ratio [OR] 1.24, 95% confidence interval [CI] 1.11–1.38) and other insurance groups (43.4%; OR 1.95, 95% CI 1.13–3.37) compared with private insurance (28.2% inadequate). After adjusting for age, race, education, obesity class, diabetes, and hypertension, payer status remained a significant predictor of inadequate prenatal care (Medicaid OR 1.18, 95% CI 1.03–1.35; “other” OR 1.85, 95% CI 1.05–3.24). CONCLUSION: Medicaid and other nonprivate insurance payer statuses are associated with higher rates of inadequate prenatal care compared with private insurance regardless of obesity status and potential confounders. The reason for less adequate care in these groups is unclear.

Association between obesity during pregnancy and the use of prenatal services.

INTRODUCTION: Approximately 25% of women in the United States are obese (body mass index greater than 30 kg/m2). Obese women are at risk for poor perinatal outcomes, and studies imply that inadequate, late onset, or both of prenatal care are contributing factors in this population. We previously demonstrated that maternal obesity is actually associated with improved adequacy of prenatal care as measured by the Kotelchuck index and now further examine the use of specific prenatal services by otherwise uncomplicated obese women. METHODS: Retrospective cohort study of medically uncomplicated women who initiated prenatal care and delivered at our institution from January 2009 to December 2011. Maternal history and delivery information were obtained through chart abstraction. Use of specific prenatal care services including diabetic screening, ultrasound examinations, and hospitalization was compared between nonobese and obese women. RESULTS: A total of 320 women were evaluated, of whom 38% were obese. Mean (±standard error) length of hospital stay for combined intrapartum and postpartum care was 3.0±0.1 days in obese women compared with 2.9±0.1 days in nonobese women (P=.4). Both populations had similar diabetic screening compliance of 86.4% for nonobese and 86.8% for obese women (P=.9). However, obesity was significantly associated with more obstetrical ultrasonographic examinations with 48% obese women having five or more ultrasound scans compared with only 25% of nonobese women (P<.05). CONCLUSION: In our population, obesity in otherwise uncomplicated pregnant women is associated with increased use of obstetric ultrasound services, but there were no differences in use of other prenatal services.