Tamima Al-Dughaishi

Nutraceuticals as Lipid-Lowering Treatment in Pregnancy and Their Effects on the Metabolic Syndrome.

Maternal nutrition and lifestyle before and during pregnancy influence both mother and offsprings health and can be correlated with the metabolic syndrome in later life. Findings from animal and human studies indicate that nutrition during pregnancy has an important role in microbiological, metabolic, physiologic and immunologic development and homeostasis. A low nutritional intake in early pregnancy may represent a risk for adverse effects during pregnancy as well as on birth outcome. It seems that dietary supplementation with probiotics in perinatal period may represent safe and practical approach in dealing with the most common adverse pregnancy outcomes such as obesity and gestational diabetes. The SPRING (Study of Probiotics in the prevention of Gestational diabetes) will give important answers about potential benefits of probiotics in pregnant women who are obese and overweight and otherwise at the high risk for complications during pregnancy. Fish oil supplementation during the last trimester of pregnancy showed no effects on plasma lipids and lipoproteins in offspring, as well as on their adiposity. The effect of hypercholesterolemia during pregnancy on both mothers and child needs to be further investigated as it could have a biological role. The guidelines for the eventual clinical approach currently do not exist. Potential benefits of nutraceuticals on several metabolic parameters have been suggested. Limited evidence does not allow to draw final conclusions on preventive health strategies and dietary patterns that should be promoted during pregnancy. Further prospective and intervention studies are needed to establish it. Healthy lifestyle and dietary advice with appropriate supplements usage should be considered.

Comparison of therapeutic lipid target achievements among high-risk patients in Oman.

We compared therapeutic lipid target achievements among patients with diabetes or coronary heart disease (CHD) in Oman. A retrospective chart review of 94 patients was conducted at an outpatient clinic in Sultan Qaboos University Hospital, Muscat, Oman. The variables included low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and apolipoprotein B (apo B). The overall mean age of the cohort was 59 ± 12 years, 54% were male, 66% were diabetic, 48% hypertensive, 45% had CHD, 94% were on simvastatin, 4% were on fenofibrate, and 2% were on both simvastatin and fenofibrate. Lipid goal attainments of calculated LDL-C (<2.6 mmol/L), apo B (<0.9 g/L), and non-HDL-C (<3.36 mmol/L) were reached in 52%, 39%, and 53% of the patients, respectively. A significant proportion of high-risk patients treated with lipid-lowering agents reach LDL-C but not the apo B treatment targets, suggesting that the use of apo B target values should also be considered.

Red Cell Alloimmunization to Rhesus Antigen Among Pregnant Women Attending a Tertiary Care Hospital in Oman.

OBJECTIVES The detection of maternal alloimmunization against red cell antigens is vital in the management of hemolytic disease of the fetus and newborn. We sought to measure the presence of allosensitization to Rhesus D (RhD) antibodies in antenatal women attending a tertiary care hospital and assess the fetal outcome in sensitized women. 
 METHODS We conducted a retrospective review of pregnant Omani women who registered at the Sultan Qaboos University Hospital between June 2011 and June 2013. Pregnant women were tested for ABO blood type and were screened for RhD antigen and antibodies at their first antenatal clinic visit. In women who tested positive for the RhD antibodies, an antibody titer was performed to evaluate the severity of their case. RESULTS Data was available on 1,251 pregnant women who were managed and delivered at Sultan Qaboos University Hospital. The prevalence of RhD negative pregnant women was 7.3%. Blood group O was the most common followed by A, B, and AB. The rate of RhD negative alloimmunization was 10%, and anti-D was the most common antibody detected. There were no stillbirths or neonatal deaths. Postnatal transfusion was necessary for only one baby. CONCLUSIONS The prevalence of RhD negativity was comparable to other Asian countries. Previous RhD alloimmunization and history of miscarriages were the most common maternal medical history.

Alloimmunization due to red cell antibodies in Rhesus positive Omani Pregnant Women: Maternal and Perinatal outcome

Objective: This study is aimed to determine the prevalence of alloimmunization due to antibodies to red blood cell (RBC) antigens (other than rhesus [Rh] antigen) and report the maternal, perinatal, and neonatal outcomes. Materials and Methods: A retrospective review of medical records of all patients with minor RBCs antibodies alloimmunization who were followed and delivered at Sultan Qaboos University Hospital, Oman from June 2011 to June 2013. Maternal characteristics, antibody type, antibody titer in addition to perinatal and neonatal outcomes were reviewed. Results: There were 1160 patients with Rh positive status in the study. The most common ABO blood group was O, followed by A, B, and AB. We found 33 out of 1160 Rh positive women alloimmunized with minor RBCs antibodies that gave a prevalence of minor RBCs alloimmunization of 2.7%. The most frequent antibody was anti-E 38%, followed by anti-c 17% and anti-kell 17%. 6 of these 33 patients were identified to have significant antibody titer, and two cases showed evidence of fetal anemia. Only one case required an intrauterine blood transfusion. The most common neonatal complication was jaundice in 53%, followed by respiratory distress syndrome in 28%. Two cases complicated by neonatal anemia required a postnatal blood transfusion. Conclusion: Alloimmunization with anti-E, anti-c, and anti-kell were the most common antibodies among the study group. Minor RBCs alloimmunization was an important cause of neonatal morbidity.

Decisions to Perform Emergency Caesarean Sections at a University Hospital: Do obstetricians agree?

OBJECTIVES This study was undertaken to assess the degree of agreement amongst obstetricians regarding decisions to perform emergency Caesarean section (CS) procedures at a university hospital. METHODS This retrospective clinical audit was carried out on 50 consecutive emergency CS procedures performed between November 2012 and March 2013 on women with singleton pregnancies at the Sultan Qaboos University Hospital in Muscat, Oman. Data on each procedure were collected from electronic patient records and independently reviewed by six senior obstetricians to determine agreement with the decision. RESULTS Of the 50 women who underwent CS procedures, the mean age was 28.9 ± 5.1 years and 48% were primigravidae. A total of 65% of the CS procedures were category I. The most common indications for a CS was a non-reassuring fetal heart trace (40%) and dystocia (32%). There was complete agreement on the decision to perform 62% of the CS procedures. Five and four obstetricians agreed on 80% and 95% of the procedures, respectively. The range of disagreement was 4-20%. Disagreement occurred primarily with category II and III procedures compared to category I. Additionally, disagreement occurred in cases where the fetal heart trace pattern was interpreted as an indication for a category II CS. CONCLUSION The majority of obstetricians agreed on the decisions to perform 94% of the emergency CS procedures. Obstetric decision-making could be improved with the implementation of fetal scalp pH testing facilities, fetal heart trace interpretation training and cardiotocography review meetings.

Use of Intracervical Foley Catheter for Induction of Labour in Cases of Previous Caesarean Section: Experience of a single tertiary centre in Oman

OBJECTIVES This study aimed to evaluate rates of success and perinatal complications of labour induction using an intracervical Foley catheter among women with a previous Caesarean delivery at a tertiary centre in Oman. METHODS This retrospective cohort study included 68 pregnant women with a history of a previous Caesarean section who were admitted for induction via Foley catheter between January 2011 and December 2013 to the Sultan Qaboos University Hospital, Muscat, Oman. Patient data were collected from electronic and delivery ward records. RESULTS Most women were 25-35 years old (76.5%) and 20 women had had one previous vaginal delivery (29.4%). The most common indication for induction of labour was intrauterine growth restriction with oligohydramnios (27.9%). Most women delivered after 40 gestational weeks (48.5%) and there were no neonatal admissions or complications. The majority experienced no complications during the induction period (85.3%), although a few had vaginal bleeding (5.9%), intrapartum fever (4.4%), rupture of the membranes (2.9%) and cord prolapse shortly after insertion of the Foley catheter (1.5%). However, no cases of uterine rupture or scar dehiscence were noted. Overall, the success rate of vaginal birth after a previous Caesarean delivery was 69.1%, with the remaining patients undergoing an emergency Caesarean section (30.9%). CONCLUSION The use of a Foley catheter in the induction of labour in women with a previous Caesarean delivery appears a safe option with a good success rate and few maternal and fetal complications.

Successful direct adsorption of lipoproteins (DALI) apheresis during pregnancy in an Omani woman with homozygous familial hypercholesterolemia

We report our experience with Direct Adsorption of Lipoproteins (DALI) apheresis in an Omani pregnant woman affected by homozygous familial hypercholesterolemia. To the best of our knowledge this is the first successful pregnancy treated with DALI apheresis. The patient had a history of coronary artery disease, supra-aortic valvular stenosis and severe carotid artery disease with right carotid artery stenting. She was on a regular biweekly DALI apheresis since 2008. In May 2013, she became pregnant and rosuvastatin and ezetimibe were stopped while she continued on DALI apheresis biweekly. This treatment during pregnancy was successful with no major complications. The average low-density lipoprotein cholesterol reduction during therapy was 50%. She spontaneously delivered a healthy male infant (2,400 g) at 37 weeks. We showed that DALI apheresis therapy was safe during pregnancy with a good outcome for both mother and neonate.

Placental tumour: What could it be?

Placental tumours include placental chorioangiomas, teratomas, haemangiomas, and haematomas. Placental chorioangiomas are benign vascular tumours and are the most common placental tumours, with a prevalence of 1%. Large placental chorioangiomas are rare and may lead to pregnancy complications and poor perinatal outcomes. These complications include fetal anaemia, hydrops fetalis, fetal growth restriction, polyhydramnios, and preterm delivery. We report a case of a large placental chorioangioma, the antenatal management and the maternal and fetal outcomes.

Statin of Preference to Treat Dyslipidaemia in Patients with Renal Dysfunction: Cues from (SATURN).

Sir, The recent conclusion of SATURN (Study of Coronary Atheroma by InTravascular Ultrasound: Effect of Rosuvastatin versus AtorvastatiN) study,1 demonstrated that maximal suggested doses of both atorvastatin and rosuvastatin ameliorate atherosclerosis to a similar extent by facilitating the regression of percent atheroma volume. Both statins, however, caused renal proteinurea, albeit to different extents. The published results of the study ephemerally state that “proteinuria was commoner in the rosuvastatin group than in the atrovastatin group (3.8% versus 1.7%)”. Further, the treatment group pertaining to atrorvastatin had higher number of diabetics compared to the group on rosuvastatin (16.8% versus 13.8%). Diabetes augments kidney failure,2,3 accounting for nearly 44% of new cases in the United States, therefore it is plausible the atorvastatin treatment group had more patients with renal dysfunction than the rosuvastatin treatment group whereby the actual reported percentage of patients with proteinuria on rosuvastatin might not reflect the true value. The median age of the participants in SATURN-trial is ∼57 years. An individual of 57 years has an average glomerular filtration rate (GFR) of 93 ml/min/1.73m2 versus 116 ml/min/1.73m2 observed in individuals 20–29 years of age, indicating a decline in renal function with advancement with age. The intriguing issue of pivotal importance remaining unanswered is “Which statin should preferably be administered in patients who are elderly with declining renal function/chronic kidney disease (CKD) patients/patients with diabetic proteinuria?” Currently, with contradicting results from several trials, a conclusive answer to the above is unavailable. As a case in point, atorvastatin exhibited reno-protective effects in the Treating to New Targets (TNT) study, but decreased estimated (e)-GFR in PLANET-I and CARDS trials.4,5 Similarly, rosuvastatin exhibited reno-protective effects in mouse-model experiments, but in PLANET-I it exhibited reno-deleterious effects as it significantly decreased e-GFR.6 The results of the SHARP trial,7 show promise where simvastin plus ezetimibe could be prescribed for patients with renal dysfunction, without plausible detrimental effects on renal health, although the trial lacked a longer follow-up period.8 Future head-to-head trials with different statins or a statins plus non-statin-cholesterol lowering drug combination, conducted in a patient population with CKD and with a suitable follow up period, are essential to answer the question posed above. In the meantime, clinicians will have to choose the statin appropriate to the need of the patient.