Obstetric Medicine current issue

Training in obstetric medicine: a global issue

Lowe, S., Nelson-Piercy, C., Rosene-Montella, K. — 2009-09-01

Sepsis in pregnancy and early goal-directed therapy

Joseph, J., Sinha, A., Paech, M., Walters, B. N J — 2009-09-01

Sepsis is a major cause of serious morbidity and mortality in pregnant women and their babies. Conventional management has evolved over many years. Improved understanding of the underlying pathophysiology and randomized clinical trials have led to recommendations for the formalization and standardization of the management of severe sepsis in non-pregnant patients. Most of these recommendations are applicable to pregnancy. The Surviving Sepsis Campaign and Early Goal Directed Therapy have relevance to the care of pregnant women with serious infection and are reviewed here.

Sleep disorders in pregnancy

Bourjeily, G. — 2009-09-01

Sleep complaints are a common occurrence in pregnancy that are in part due to pregnancy-associated anatomic and physiological changes but may also be due to pathological causes. In the non-pregnant population, sleep deprivation has been associated with physical and cognitive issues; poor sleep may even be associated with adverse maternal outcomes. Maternal obesity, one of the most prevalent risk factors in obstetric practices, together with physiologic changes of pregnancy predispose to the development of sleep disordered breathing. Symptoms of sleep disordered breathing have also been associated with poor maternal outcomes. Management options of restless legs syndrome and narcolepsy pose a challenge in pregnancy; benefits of therapy need to be weighed against the potential harm to the fetus. This article briefly reviews the normal changes in pregnancy affecting sleep, gives an overview of certain sleep disorders occurring in pregnancy, and suggests management options specific for this population.

Risk perception and unrecognized type 2 diabetes in women with previous gestational diabetes mellitus

Malcolm, J., Lawson, M. L, Gaboury, I., Keely, E. — 2009-09-01

Women with a history of gestational diabetes mellitus (GDM) have a high chance of developing type 2 diabetes mellitus (T2DM) following the index pregnancy, however, little is known of women's perception of this risk. The objectives were to (1) determine women's perception of risk of future development of T2DM following a GDM pregnancy and (2) describe the prevalence of undetected dysglycaemia in a Canadian population. The study was designed as a 9–11 year follow-up study of women previously enrolled in a randomized controlled trial of tight versus minimal intervention for GDM. Women's perception of future risk of diabetes was determined by questionnaire. Fasting lipid profile, height and weight were performed on all participants. Oral glucose tolerance tests were performed on all women without prior history of diabetes mellitus type 2 (DM2). The study was conducted at Ottawa Hospital General Campus and Children's Hospital of Eastern Ontario, in Ottawa, Canada. Eighty-nine of 299 (30%) of the original cohort were recruited. Eighty-eight women completed the questionnaire and 77 women without known diabetes underwent two hour glucose tolerance testing. Twenty-three (30%) felt their risk was no different than other women or did not know, 27 (35%) felt risk was increased a little and 27 (35%) felt risk was increased a lot. Only 52% (40/77) had normal glucose tolerance. Of all, 25/88 (28%) patients had diabetes (11 previously diagnosed and 14 diagnosed within the study). Of those newly diagnosed with DM2, four (29%) were diagnosed by fasting glucose, six (42%) by two hour glucose tolerance test (GTT) alone and four (29%) by both. Twenty-four of the women (27%) had impaired glucose tolerance (IGT). Of those with IGT, 12 (57%) had a fasting food glucose < 5.6 mmol/L. In the high-risk perception group with newly diagnosed diabetes, two were overweight, seven were obese, four had a family history of DM2, and all had a waist circumference >88 cm. In conclusion the perception of being at high risk for T2DM did not prevent women from having undetected T2DM. Many factors are likely to contribute to this, including the reliance on screening tests (i.e. fasting glucose) rather than a two hour GTT to detect diabetes. Further studies on effective public and health-care provider education and intervention are needed to identify this high-risk population.

Thromboelastography and peripartum coagulation profiles associated with caesarean section delivery

Smith, R, Campbell-Owen, T, Maybury, H, Pavord, S, Waugh, J — 2009-09-01

Thromboembolic (TE) disease remains the leading direct cause of maternal death in the UK and caesarean section increases TE risk. Women are assessed for their TE risk and may receive thromboprophylaxis. From a single blood sample thromboelastography^® (TEG^®) allows a test of coagulation. Blood samples from women undergoing elective caesarean sections were collected at specific stages: antenatally, following overnight ‘nil-by-mouth’, immediately after surgery, four hours post-delivery and 24 hours post-delivery. Analyses of the R time (time taken for blood to clot) and maximum amplitude (MA) (overall clot strength) were performed. Analyses of the high and moderate risks cohorts were performed and compared to the low risk group.

Fifty-four women were recruited. A reduction in the R time was demonstrated following pre-operative fluid restriction and a further reduction in R time occurred after surgery. The R time increased 24 hours after surgery and became comparable to pre-operative levels. The MA changed similarly due to pre-operative fluid restriction. Analysis also showed that pre-operatively, the combined high and moderate risk groups’ R time was shorter than the low risk group. The high and moderate risk group, having received thromboprophylaxis, had similar R times 24 hours postoperatively compared to the low risk group. TEG^® demonstrates that following pre-operative fluid restriction and surgery women become hypercoagulable but by 24 hours coagulation has returned to third trimester levels. Sub-group analysis suggests the relative pre-operative hypercoagulability of high and moderate risk women compared to low risk women, becoming comparable after 24 hours following thromboprophylaxis.

Blood pressure measurement in pregnancy: the effect of arm circumference and sphygmomanometer cuff size

Kho, C. L, Brown, M. A, Ong, S. L H, Mangos, G. J — 2009-09-01

This study aimed to assess the difference in blood pressure readings between the standard and large cuff and to determine if such a difference applies over a range of arm circumferences (ACs) in pregnancy. We measured blood pressure on 219 antenatal women. Six blood pressure readings were taken, three with a standard ‘adult’ and three with a ‘large’ cuff, in random order. A random zero sphygmomanometer was used by a trained observer. Women with an AC >33 cm were similar in age, gestational age and parity but were heavier and had more hypertension than those with AC ≤33 cm. There was a systematic difference between the standard and large cuff of 5–7 mmHg with little effect due to AC. We were unable to demonstrate an association between the standard and large cuff blood pressure difference and increasing blood pressure. Our study has shown that both systolic and diastolic blood pressure measurements are more dependent on the cuff size used than AC and for the individual it is difficult to predict the magnitude of effect the different cuff sizes will have on blood pressure measurements. This study has shown the presence of an average difference in blood pressure measurement between standard and large cuffs in pregnancy, and does not support the arbitrary 33 cm ‘cut-off’ recommended in guidelines for the use of a large cuff in pregnancy.

Serum cystatin is not a marker of glomerular filtration rate in pregnancy

Bramham, K., Makanjuola, D., Hussein, W., Cafful, D., Shehata, H. — 2009-09-01

The role of cystatin C (Cys-C) as a marker of glomerular filtration rate (GFR) in pregnancy is undetermined. Measurements of Cys-C and creatinine (Cr) were taken at 14–17⁺⁶, 18–23⁺⁶, 27–31⁺⁶ weeks' gestation, at delivery and 2–6 weeks postpartum in a prospective observational study of 27 women. There was no difference between Cys-C levels in early and late second trimester, but they were significantly higher in early third trimester (P < 0.001) than second trimester, despite no concurrent increase in Cr. Cys-C was also significantly higher at delivery than at all other times in pregnancy (P < 0.001) and fell to postpartum values higher than second trimester measurements (P < 0.01), but lower than delivery (P<0.001). In conclusion, changes in Cys-C may be influenced by pregnancy-related changes in glomerular filtration and therefore we would advise against their use as a marker of GFR in pregnancy.

Hereditary angioedema and pregnancy: successful management of recurrent and frequent attacks of angioedema with C1-inhibitor concentrate, danazol and tranexamic acid - a case report

Milingos, D S, Madhuvrata, P, Dean, J, Shetty, A, Campbell, D M — 2009-09-01

Hereditary angioedema (HAE) is a rare but potentially life-threatening condition caused by deficiency of C1 esterase inhibitor. It is characterized by subcutaneous swelling in any part of the skin, gastrointestinal and respiratory tracts. We present the case of a pregnant woman with known HAE that deteriorated during pregnancy with frequent attacks that were managed successfully with danazol, tranexamic acid and regular intravenous administration of C1 esterase inhibitor.

A rare case of idiopathic thrombocytopenia in association with an ovarian teratoma in pregnancy

Soma-Pillay, P, Macdonald, A P, Mnisi, E — 2009-09-01

Thrombocytopenia complicates 6–7% of pregnancies. We present the case of a 26-year-old patient who presented with severe thrombocytopenia associated with an ovarian teratoma in the second trimester of pregnancy.

Gilles de la Tourette syndrome in pregnancy: a retrospective series

Stern, J S, Orth, M, Robertson, M M — 2009-09-01

Tourette syndrome is a neuropsychiatric syndrome characterized by motor and vocal tics with further co-morbidities, e.g. obsessive–compulsive disorder and attention deficit hyperactivity disorder. There is only a single prior case report in pregnancy in addition to a postal questionnaire study including 10 pregnancies. In a series of 11 pregnancies in patients assessed by the authors, there were no adverse effects on the pregnancy, although some obstetricians were unduly concerned. There was no consistent effect on the severity of the tics, although in some women there seemed to be a significant improvement during pregnancy.

Renal Disease in Pregnancy

Joseph, G., Hladunewich, M. — 2009-09-01

Heart Disease in Pregnancy, 2nd Edition

Head, C. — 2009-09-01

Errata

2009-09-01

Errata

2009-09-01

Errata

2009-09-01

Successful use of dexamethasone when prednisolone is not tolerated

Heazlewood, V J, Ratnapala, M, Cochrane, L — 2009-09-01

Intrauterine growth rates in diabetic pregnancies and clinical outcomes

Peek, M., Nanan, R. — 2009-09-01