Yael Baumfeld

Severity of Acute Kidney Injury and Two-Year Outcomes in Critically Ill Patients

BACKGROUND The association between levels of acute kidney injury (AKI) during ICU admission and long-term mortality are not well defined. METHODS We examined medical records of adult patients admitted to a large tertiary medical center with no history of end-stage renal disease who survived 60 days from ICU admission between 2001 and 2007. Demographic, clinical, physiologic, and date of death data were extracted. RESULTS Among 15,048 patients, 12,399 (82.4%) survived 60 days from ICU admission and comprised the study population. AKI did not develop in 5,663 (45.7%) during ICU admission, whereas progressively severe levels of AKI as defined by Acute Kidney Injury Network (AKIN) criteria AKIN 1, AKIN 2, and AKIN 3 developed in 4,589 (37.0%), 1,613 (13.0%), and 534 (4.3%), respectively. Only 42.5% of patients with AKIN 3 survived 2 years from ICU admission. Patients with AKIN 3 had a 61% higher mortality risk 2 years from ICU discharge compared with patients in whom AKI did not develop. Patients with AKIN 1 and AKIN 2 had similar increased mortality risk 2 years from ICU admission (hazard ratio, 1.26 and 1.28, respectively). The level of estimated glomerular filtration rate on ICU discharge and chronic kidney disease were associated with long-term mortality. CONCLUSIONS Patients in whom AKI develops during ICU admission have significantly increased risks of death that extend beyond their high ICU mortality rates. These increased risks of death continue for at least 2 years after the index ICU admission.

Gestational Diabetes Mellitus Is a Significant Risk Factor for Long-Term Maternal Renal Disease

CONTEXT Gestational diabetes mellitus (GDM) was found to be an independent risk factor for recurrent long-term type 2 diabetes mellitus, cardiovascular morbidity, and vascular endothelial dysfunction. However, data on the link between GDM and future risk for long-term maternal renal disease are limited. OBJECTIVE The purpose of this study was to investigate whether GDM poses a risk for subsequent long-term maternal renal morbidity. DESIGN A population-based noninterventional study compared the incidence of future renal morbidity in a cohort of women with and without previous GDM. Deliveries occurred during a 25-year period, with a mean follow-up duration of 11.2 years. SETTING The study was conducted at the Soroka University Medical Center. PARTICIPANTS The study population was composed of all singleton pregnancies in women who delivered between January 1988 and December 2013. MAIN OUTCOME MEASURE The main outcome was diagnosis of renal morbidities. RESULTS Of 97,968 women who met the inclusion criteria, 9542 (9.7%) had at least 1 previous pregnancy with GDM. Using a Kaplan-Meier survival curve, we show that women with GDM had higher rates of total renal morbidity (0.1% vs 0.2%, for no GDM and with GDM, respectively; odds ratio, 2.3, 95% confidence interval, 1.4-3.7; P < .001). In addition, we found a significant dose-response association (using the χ(2) test for trends) between the number of pregnancies with GDM and future risk for renal morbidity (0.1%, 0.2%, and 0.4% for no GDM, 1 episode of GDM, and 2 episodes of GDM, respectively; P < .001). In a Cox proportional hazards model, adjusted for confounders, GDM was independently associated with future renal morbidity. CONCLUSION GDM is a significant risk factor for future maternal renal morbidity. The risk is more substantial for patients with recurrent episodes of GDM.

Trends in severity of illness on ICU admission and mortality among the elderly

Background There is an increase in admission rate for elderly patients to the ICU. Mortality rates are lower when more liberal ICU admission threshold are compared to more restrictive threshold. We sought to describe the temporal trends in elderly admissions and outcomes in a tertiary hospital before and after the addition of an 8-bed medical ICU. Methods We conducted a retrospective analysis of a comprehensive longitudinal ICU database, from a large tertiary medical center, examining trends in patients’ characteristics, severity of illness, intensity of care and mortality rates over the years 2001–2008. The study population consisted of elderly patients and the primary endpoints were 28 day and one year mortality from ICU admission. Results Between the years 2001 and 2008, 7,265 elderly patients had 8,916 admissions to ICU. The rate of admission to the ICU increased by 5.6% per year. After an eight bed MICU was added, the severity of disease on ICU admission dropped significantly and crude mortality rates decreased thereafter. Adjusting for severity of disease on presentation, there was a decreased mortality at 28- days but no improvement in one- year survival rates for elderly patient admitted to the ICU over the years of observation. Hospital mortality rates have been unchanged from 2001 through 2008. Conclusion In a high capacity ICU bed hospital, there was a temporal decrease in severity of disease on ICU admission, more so after the addition of additional medical ICU beds. While crude mortality rates decreased over the study period, adjusted one-year survival in ICU survivors did not change with the addition of ICU beds. These findings suggest that outcome in critically ill elderly patients may not be influenced by ICU admission. Adding additional ICU beds to deal with the increasing age of the population may therefore not be effective.

Pre-Conception Dyslipidemia Is Associated with Development of Preeclampsia and Gestational Diabetes Mellitus

Introduction The association between glucose intolerance, elevated blood pressure and abnormal lipid levels is well established and comprises the basis of metabolic syndrome pathophysiology. We hypothesize that abnormal preconception lipid levels are associated with the increased risk of severe pregnancy complications such as preeclampsia and gestational diabetes mellitus. Methods We included all singleton deliveries (n = 27,721) of women without known cardiovascular morbidity and preeclampsia and gestational diabetes mellitus during previous pregnancies. Association between preconception low high density lipoprotein cholesterol (HDLc level≤50 mg/dL), high triglycerides (level≥150 mg/dL) and the primary outcome (composite of gestational diabetes mellitus/or preeclampsia) was assessed using Generalized Estimation Equations. Results Primary outcome of preeclampsia and/or gestational diabetes was observed in a total of 3,243 subjects (11.7%). Elevated triglycerides and low HDLc were independently associated with the primary outcome: with odds ratio (OR) of 1.61 (95% CI 1.29–2.01) and OR = 1.33 (95% CI 1.09–1.63), respectively, after adjusting for maternal age, weight, blood pressure, repeated abortions, fertility treatments and fasting glucose. There was an interaction between the effects of HDLc≤50 mg/dL and triglycerides≥150 mg/dL with an OR of 2.69 (95% CI 1.73–4.19). Conclusions Our analysis showed an increased rate of preeclampsia and/or gestational diabetes in women with low HDLc and high triglycerides values prior to conception. In view of the severity of these pregnancy complications, we believe this finding warrants a routine screening for the abnormal lipid profile among women of a child-bearing age.

Fetal heart rate monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis.

Abstract Objective: To determine whether fetal heart rate (FHR) monitoring categories during the 1st and 2nd stage of labor can predict arterial cord pH <7.2. Materials and methods: A case control study was conducted including 653 consecutive term deliveries (37 weeks gestation and above) that were divided according to fetal pH ≤ 7.2 (n = 315) and fetal pH > 7.2 (n = 338). Deliveries occurred during the year 2013 in tertiary medical center, where arterial cord pH is routinely taken after birth. Intrapartum FHR monitoring categorization was defined according to the ACOG committee guidelines by two obstetricians. Multivariable models were constructed to control for confounders. Results: Variable decelerations, late decelerations and bradycardia during the 1st and 2nd stages of labor were significantly higher in group of deliveries ended in cord pH < 7.2 compared with group of deliveries ended in cord pH > 7.2. A significant association was observed between category 2 and 3 during the 1st stage of labor and pH ≤ 7.2. However, while controlling for FHR category 3 at the 2nd stage of labor, 1st stage categorization lost its association with pH <7.2, and only category 3 during the 2nd stage were noted as an independent risk factor for acidosis. Conclusion: FHR monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis as expressed by arterial cord pH < 7.2.

Bicornuate uterus is an independent risk factor for cervical os insufficiency: A retrospective population based cohort study

Abstract Introduction: The purpose of our study was to explore maternal and fetal outcomes in the second and third trimester in women with bicornuate uterus. Methods: A total of 280,106 pregnancies met the inclusion criteria and were divided in two study groups: (1) pregnancies in women with bicornuate uterus (n = 444); and (2) controls (n = 279,662). The diagnosis of bicornuate uterus was performed in all patients during the workup for infertility or recurrent pregnancy loss, during pregnancy, or at the time of cesarean delivery. Multivariate logistic regression models were performed in order to assess the risk factors for cervical insufficiency in women with bicornuate uterus. Results: The rate of women with a bicornuate uterus in our population was 0.15%. Women with bicornuate uterus had lower parity (2.93 ± 1.90 vs. 3.42 ± 2.51, p < 0.001) and a higher rate of previous cesarean deliveries (54.1% vs. 12.3%, p < 0.001). In addition, these patients were more prone to conceive with assisted reproductive techniques (5.6% vs. 1.9%, p < 0.001) and had a significantly higher rate of recurrent abortions (12.4% vs. 5.1%, p < 0.001) compared to controls. Conclusions: Bicornuate uterus is an independent risk factor for cervical os insufficiency. This is an important finding due to the burden of the risk for midtrimester periviable birth associated with cervical incompetence.

Meconium-stained amniotic fluid – risk factors and immediate perinatal outcomes among SGA infants

Abstract Objective: To detect factors that are associated with meconium-stained amniotic fluid (MSAF) among deliveries of small for gestational age (SGA) neonates and to identify perinatal outcomes of deliveries of SGA infants complicated with MSAF. Methods: A population-based study comparing deliveries of SGA neonates with and without MSAF was conducted. Deliveries occurred during the years 1988–2007 at the Soroka University Medical Center. Risk factors for MSAF among SGA infants were evaluated. Incidence of adverse pregnancy outcomes were compared between deliveries of SGA neonates with and without MSAF. Results: During the study period 9583 deliveries were of SGA neonates. Of these, 16.6% (n = 1597) were complicated with MSAF. Among SGA neonates, older maternal age, multiparty, lack of prenatal care and weight were significantly associated with MSAF. Having delivered an SGA infant with MSAF was associated with decreased rates of induction of labor and increased rates of labor dystocia, delivery by cesarean section and fetal distress. Using multivariable regression models, having delivered an SGA infant with MSAF was independently associated with fetal distress. Conclusion: Among SGA neonates, deliveries complicated with MSAF are associated with additional adverse pregnancy outcomes.

Placenta previa associated with severe bleeding leading to hospitalization and delivery: a retrospective population-based cohort study

Abstract Introduction: The aim of our study was to compare maternal and neonatal outcomes in women with placenta previa complicated with severe bleeding leading to hospitalization until delivery versus those without severe bleeding episodes. Methods: This is a population-based retrospective cohort study including all pregnant women with placenta previa who delivered at our medical center in the study period, divided into the following groups: 1) women with severe bleeding leading to hospitalization resulting with delivery (n = 32); 2) patients with placenta previa without severe bleeding episodes (n = 1217). Results: Out of all women with placenta previa who delivered at our medical center, 2.6% (32/1249) had an episode of severe bleeding leading to hospitalization and resulting with delivery. The rate of anemia was lower (43.8% versus 63.7%, p = 0.02) while the need for blood transfusion higher (37.5% versus 21.1%, p = 0.03) in the study group. The rate of cesarean sections was significantly different between the groups, and a logistic regression model was constructed in order to find independent risk factors for cesarean section in our patients. Conclusion: To the best of our knowledge, this is the first study to evaluate the impact of severe bleeding on the outcome of pregnancies complicated with placenta previa. Our study demonstrates that, in women with placenta previa, severe bleeding does not lead to increased adverse maternal or neonatal outcomes.

Association between hypertensive disorders of pregnancy and third stage of labor placental complications

OBJECTIVE To examine the association between hypertensive disorders of pregnancy and third stage placental complications. METHODS A retrospective cohort study based on Soroka Medical Center institutional computerized database. All vaginal deliveries of women between the years 1998-2013 were included. Rates of third placental complications and other adverse pregnancy outcomes were compared between parturients with and without hypertensive disorders of pregnancy. Multivariate analysis models as well as generalized equations models (GEE) controlling for potential confounders were constructed. RESULTS Of 263,053 deliveries included, 14,754 (5.6%) were complicated by hypertensive disorders of pregnancy. Hypertensive parturients were older, had higher rates of: diabetes, previous cesarean section and induction of labor. Rates of third stage placental complications were significantly higher among hypertensive parturients (4.7% versus 4.0%, p value <0.001). Preeclampsia was found independently associated with third placental complication in the logistic regression and the GEE models constructed. Adjusted odds ratio, 95% confidence interval, respectively: 1.11 (1.00-1.24); 1.11 (1.00-1.25). CONCLUSION Our study was the first to demonstrate that an association between hypertensive disorders of pregnancy and third stage placental complications exists, suggesting a common pathological pathway. Further larger studies are needed in order to reinforce these findings.

Risk factors for obstetric anal sphincter injuries (OASIS) during vacuum extraction delivery in a university affiliated maternity hospital

Abstract Introduction: Instrumental delivery is a well-known risk factor for obstetric anal sphincter injuries (OASIS). The specific characteristics among patient undergoing vacuum extraction delivery (VE) are less studied. Therefore, we aimed to evaluate risk factors for OASIS among parturient that underwent a VE delivery in a large university affiliated maternity hospital. Material and methods: The study population contained 9116 women who delivered by VE in tertiary medical center from 1988 to 2015. Inclusion criteria included deliveries beyond 24-week gestation. Multiple gestations and pregnancies complicated with stillbirth were excluded from the analysis. Maternal obstetric variables were compared between parturient with and without OASIS. Independent risk factors for OASIS were assessed by multivariable logistic regression modeling. Results: OASIS was diagnosed in 94 women (1.03%) following vacuum extraction. Among patients who underwent a VE delivery, gravidity and parity were found to be significantly lower in patients with OASIS. A multivariable logistic regression model with OASIS as the outcome variable revealed that among women who underwent VE, while episiotomy and delivery of a macrosomic neonate were not independently associated with OASIS, a strong association between nulliparity and OASIS was found (OR 3.34; 95% CI 1.93–5.78; p < .001). Conclusions: OASIS is uncommon in our population. Vacuum extraction in nulliparous parturient is a significant risk factor for OASIS. Our results should be taken into account when managing nulliparous deliveries.