SOMANZ abstract packet

1: Climate change and women's health

Kristine Barnden ¹

1. Royal Hobart Hospital, NEW TOWN, TAS, Australia

The Lancet described climate change as the greatest global health threat of the twenty-first century. This talk will focus on the effects of heat and poor air quality on pregnancy outcomes, and strategies to minimise harm. Climate change magnifies existing inequalities, and on a global and national scale women are especially vulnerable to the effects of climate change. Reversing gender inequalities is associated with benefits for climate mitigation and adaptation.

2: Making a difference after natural disasters – reducing the influence of prenatal flood-related stress on pregnancy and childhood outcomes

Katrina Moss ¹

1. Australian Women and Girls Health Research Centre, The University of Queensland, Herston, QLD, Australia

Natural disasters, like floods, can have widespread impacts on communities, including babies in utero. The QF2011 Study worked with women who were pregnant during the 2011 Queensland floods and assessed stress during pregnancy and child development throughout early childhood. Dr Moss built on this work after joining the Australian Longitudinal Study on Women's Health (ALSWH), investigating links between maternal depression during the child's early life course (pre-conception, pregnancy and early childhood) and childhood development. Prenatal maternal stress was linked with a range of adverse outcomes in children, including difficult temperament, lower social skills, poorer cognitive and motor development, and a higher likelihood of behaviour, sleep and interpersonal problems. Chronic or ongoing stress was also important, with longer exposure linked with poorer outcomes for children. However, these negative consequences are not inevitable: five key strategies can make a difference. 1) Minimise diet changes, which includes keeping up multivitamins and not skipping meals. 2) See the same midwife (midwifery group care was associated with less stress in mothers and better development in children). 3) Use emotionally-available parenting strategies such as sensitivity and structuring, which can buffer the effects of high prenatal stress on child development. 4) Match coping strategies to the situation, using emotional focused strategies (e.g., reframing, acceptance, emotional support) for stressors that are uncontrollable and problem-focused strategies (e.g., planning, instrumental support) for stressors where actions can make a difference. Limit the use of dysfunctional strategies such as denial, self-blame and venting. 5) Screen for perinatal mental health problems, including post-traumatic stress symptoms. Screening should occur during pregnancy and in the first postnatal year but 20% of Australian women do not receive the recommended screening. This is particularly important following natural disasters. Natural disasters can be devastating and effects can linger long after flood waters subside. Working together though, we can make a difference for mothers and babies caught up in these events.

3: Long-term health after hypertensive disorders of pregnancy: addressing knowledge gaps in Australian women and healthcare providers

Heike Roth^1,2, Amanda Henry^3,1,2, Caroline SE Homer^4,1

1. Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia

2. St George and Sutherland Clinical School, Faculty of Medicine, University of NSW, Sydney, NSW, Australia

3. School of Clinical Medicine, UNSW Medicine & Health, University of NSW, Sydney, NSW, Australia

4. Maternal and Child Health, Burnet Institute, Melboure, VIC, Australia

Hypertensive disorders of pregnancy, (HDP) including chronic hypertension, preeclampsia and gestational hypertension, complicate 5–10% of pregnancies and are associated with long-term cardiovascular and other chronic disease sequelae, including Type 2 diabetes mellitus and chronic renal disease. For women who have experienced HDP, cardiovascular disease (CVD) rates are 2–3 times higher compared with those who did not. This risk of premature disease and death is present within 10 years after the affected pregnancy, remains after adjusting for the presence of other cardiovascular risk factors, and is further increased in early-onset and recurrent HDP.

The link between preeclampsia and CVD has been known for many years, with the first meta-analysis published in 2007. Both Australian and international societies, including SOMANZ and the International Society for the Study of Hypertension in Pregnancy (ISSHP), recommend that women and healthcare providers are provided with information about HDP and later CVD.

Despite the length of time that this topic has been addressed in research, knowledge has not translated into practice. Research conducted by our team in Australia has identified knowledge gaps around health after HDP. Whilst overall healthcare providers were aware that there is increased cardiovascular risk after preeclampsia, they were less aware of risks after gestational hypertension and some specific risks including diabetes. Only one third of participants were aware about the risks starting to manifest within 10 years after HDP. Regarding how to close the knowledge to practice gap, we identified that both women and HCPs wanted more information about long-term and modifiable risk factors post-HDP, and a more structured transition from hospital to community health post-HDP, including automated alerts to remind women about key follow-up appointments.

Our research team is now seeking to implement these findings, evaluating a program for women, general practitioners, and other primary healthcare providers. Ultimately, we aim to improve care of women following HDP, and contribute to improving women's health trajectories. This talk will summarise work to date including progress on implementation studies.

4: Altered regulation of placental Olah may contribute to the pathogenesis of preeclampsia and fetal growth restriction

Natasha de Alwis^1,2, Sally Beard^1,2, Natalie K Binder^1,2, Natasha Pritchard^1,2, Tu'uhevaha J Kaitu'u-Lino^1,2, Sue P Walker^1,2, Owen Stock¹, Katie Groom³, Scott Petersen⁴, Amanda Henry⁵, Joanne M Said^1,6, Sean Seeho⁷, Stefan C Kane^1,8, Stephen Tong^1,2, Lisa Hui^1,2, Natalie J Hannan^1,2

1. Department of Obstetrics and Gynaecology, University of Melbourne, Carlton, VIC, Australia

2. Mercy Perinatal, Mercy Hospital for Women, Melbourne, Victoria, Australia

3. Liggins Institute, University of Auckland, Auckland, New Zealand

4. Centre for Maternal Fetal Medicine, Mater Mothers’ Hospital, Brisbane, Queensland, Australia

5. School of Women's and Children's Health, UNSW Health, University of New South Wales, Sydney, New South Wales, Australia

6. Maternal Fetal Medicine, Joan Kirner Women's & Children's Sunshine Hospital, Melbourne, Victoria, Australia

7. The University of Sydney Northern Clinical School, Women and Babies Research, Sydney, New South Wales, Australia

8. Department of Maternal Fetal Medicine, Royal Women's Hospital, Melbourne, Victoria, Australia

Background: Placental dysfunction is a key feature of preeclampsia and fetal growth restriction (FGR). Transcripts of Oleoyl-ACP Hydrolase (OLAH), a molecule involved in fatty acid synthesis, were found to be highly elevated in the maternal circulation of pregnancies complicated by preterm FGR (± preeclampsia). Here, we aimed to examine OLAH levels in the placenta, and whether OLAH has a role in placental dysfunction and the pathogenesis underlying these serious conditions.

Methods: OLAH transcripts were measured in the maternal circulation of cases of preterm FGR, assessing changes with preeclampsia, and fetal hypoxia (qPCR). OLAH gene expression (qPCR) was assessed in first trimester (7–10 weeks), late second trimester (24–28 weeks) and third trimester (38–39 weeks) placental tissues. OLAH expression (qPCR) and protein (western blot) were assessed in placenta from cases of preterm preeclampsia, FGR, and gestation-matched controls. OLAH gene expression was also assessed in whole placental explant tissue and isolated primary cytotrophoblast under hypoxic (1% O₂; modelling placental dysfunction) versus physiological normoxic (8% O₂) conditions. Using short interfering RNAs, we silenced cytotrophoblast OLAH expression, and tested secretion (ELISA) of the anti-angiogenic factor sFLT-1 and pro-angiogenic factor PlGF (factors dysregulated in preeclampsia), and expression of genes associated with apoptosis, growth, oxidative stress, and inflammation.

Results: Previously, we found OLAH transcripts were elevated in the maternal circulation with FGR; here we found that OLAH transcripts in these cases were not further altered with coexistent preeclampsia, or fetal hypoxia (umbilical artery blood pH < 7.2). OLAH expression was significantly higher in second and third trimester placentas, compared to first trimester. Placenta from cases of preeclampsia, but not FGR, had significantly higher OLAH expression compared to controls. Placental tissue from the complicated pregnancy groups did not have altered OLAH protein compared to controls. However, OLAH protein levels were significantly higher in placenta from cases of preeclampsia compared to FGR placentas. Culture under hypoxic conditions increased OLAH expression in placental explant tissue, but not cytotrophoblasts. Silencing OLAH in cytotrophoblasts did not alter sFLT-1 or PlGF secretion, but significantly reduced expression of BAX (pro-apoptosis), BCL2 (anti-apoptosis), IGF2 (important for fetal growth), and NOX4 (oxidative stress marker).

Conclusion: Placental OLAH expression is altered in pregnancies complicated by preeclampsia and FGR, and in ex vivo models of placental dysfunction. These data suggest OLAH could play a role in placental dysfunction, possibly though regulation of oxidative stress or canonical fatty acid regulation and thus, targeting OLAH may offer new options for therapeutic development.

5: Risk factors for post-partum representation to hospital with hypertension

Helen McDougall¹, Nadia Olivier¹, Grace Yuan², Mark Tacey¹, David Langsford^2,1

1. The Northern Hospital, Epping, VIC, Australia

2. The University of Melbourne, Parkville, VIC, Australia

Background: Unplanned representation to hospital post-partum is burdensome for patients and families, and costly to health systems. Hypertension is one of the leading causes. Support programs have been shown to reduce hypertension representation, but identifying those at risk can be difficult with up to half of those readmitted with no previous diagnosis of hypertension.

Aim: To establish the rate of post-partum hypertension representation at Northern Health and compare characteristics with those who are not readmitted with hypertension.

To develop a model identifying women at risk of hypertension representation.

Methods: We identified all deliveries at Northern Health from 1^st January 2016 to 31^st December 2020 using discharge summary coding data.

International Classification of Diseases 10^th ed (ICD-10) codes combined with a manual medical records search identified all deliveries that resulted in representation to hospital with hypertension.

A structured manual medical records search combined with coding data compared a randomised sample of all deliveries who were not readmitted with hypertension, to all patients who were. A multivariable analysis identified independent risk factors for readmission.

Bootstrapping was used to rank factors based on probability of inclusion. The area under the receiving operator characteristic (ROC) curve or C-stat was used to test the final model's discriminative ability.

Results: From 1^st January 2016 to 31^st December 2020 there were 17746 deliveries at Northern Health. 656 deliveries (3.6%) resulted in representation to hospital. 72 of the representations were related to hypertension (0.4% of all deliveries).

The women who represented were of greater mean age (32, 30), with higher median BMI (31, 26), they had higher median peak systolic blood pressure in the delivery admission (150 mmHg v 131 mmHg) and only 48.6% had a previous diagnosis of hypertension.

The highest performing risk model had 6 factors: gestational hypertension, pre-eclampsia, peak systolic blood pressure, 3 or more hypertensive blood pressure readings, elective caesarean and antenatal aspirin prescription with a C-stat of 0.90.

Discussion: Our risk model may more reliably predict hypertension readmission than three previously published models, with an AUC of 0.90 compared to 0.83–0.85. This needs to be verified in a validation cohort.

This study is limited by being retrospective. The use of aspirin and pre-eclampsia may limit reliability over time as guidelines and trends in prescription and diagnosis change.

Once verified, our model could identify patients for programs aimed at preventing post-partum representation as well as the short and long term complications of post-partum hypertension.

6: Is there a role for postpartum lifestyle intervention in improving mental health after hypertensive disorders of pregnancy?

Emily K Fergusson¹, Amanda Henry^2,3, Amanda Beech⁴, Lynne Roberts⁵, Judith Roche⁶

1. UNSW Medicine, University of New South Wales, Sydney, NSW

2. School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, NSW

3. Department of Women's and Children's Health, St George Hospital, Sydney, NSW

4. Obstetrics and Gynaecology, Endocrinology, Royal Hospital for Women, Sydney, NSW

5. Obstetrics Medicine Research Group, St George Hospital, Sydney, NSW

6. Royal Hospital for Women, Sydney, NSW

Background: Hypertensive disorders of pregnancy (HDP) are estimated to complicate between 5–10% of pregnancies and are associated with the development of postpartum mental illness. HDP are also associated with ongoing cardiometabolic health issues, and healthy lifestyle is recommended postpartum to reduce future risk. The purpose of this study was to assess whether lifestyle intervention designed to improve physical health had an impact on the mental health of participants between 6- and 12-months postpartum.

Method: Sub-study of Blood Pressure Postpartum (BP²), a randomised controlled trial investigating follow-up/lifestyle intervention for women after HDP. Participants were randomised to Optimised Usual Care, Brief Education Intervention or Extended Lifestyle Intervention. Data were obtained from the 6-month baseline and 12-month follow-up BP² questionnaires. These included the Edinburgh Postnatal Depression Scale (EPDS), General Anxiety Disorder 7-item scale (GAD-7), NSW Health Population Survey and EQ-5D-5L Questionnaire, to assess quality of life, depression and anxiety levels at 6- and 12-months postpartum. The major subgroups compared were: (1) intervention group and (2) HDP diagnosis (Chronic Hypertension CH, Gestational Hypertension GH, Preeclampsia PE and Chronic Hypertension Superimposed with Preeclampsia CH + PE). Wilcoxon signed-rank test and McNemar's test were used to compare paired 6- and 12-month data.

Results: 201 women (27CH, 59 GH, 100PE, 15PE + CH) had completed 6- and 12-month assessments by August 2021. Average age was 34.0 ± 5.6 years, 41% born overseas, 73% Caucasian, 71% first baby. A subset of 80 women had completed EPDS and GAD-7 at 6- and 12-months. We found depression and anxiety on screening were substantial, but similar at 6- and 12-months postpartum, regardless of randomised intervention group. Overall, 18% of women at 6-months and 15% at 12-months scored above EPDS screening threshold (EPDS ≥ 11), while 10% at 6-months and 9% at 12-months scored above GAD-7 screening threshold (GAD-7 ≥ 10). A non-significantly higher proportion of Brief Education Intervention and Extended Lifestyle Intervention women had improved EPDS (50% and 52% respectively), compared to the Optimised Usual Care group (37%), between 6- and 12-months. Non-HDP factors associated with EPDS and GAD-7 scores above threshold at 6- and/or 12-months were Intensive Care Unit admission, preterm birth, emergency caesarean and single relationship status.

Conclusions: We found a substantial group of women had poor mental health outcomes at 6- and 12-months postpartum which require attention. Although not reaching statistical significance, greater postpartum intervention may also be of mental health benefit to women after HDP. For more definitive conclusions final completed study will be required.

7: Blood pressure postpartum RCT: women's physical outcomes at six versus twelve months postpartum after hypertensive pregnancy

Zohara Mendis¹, Franziska Pettit², Amanda Henry^1,2, Lynne Roberts²

1. UNSW Medicine, UNSW, Kensington

2. School of Clinical Medicine, St George and Sutherland Clinical Campus, Sydney

Background and Aim: Hypertensive Disorders of Pregnancy (HDP), which affect up to 10% of pregnancies, are associated with ongoing women's health issues including a life-time doubled risk of cardiovascular disease (CVD). While the postpartum period can be a window of opportunity to identify CVD risk and implement interventions, evidenced-based guidelines for long term follow-up and management are sparse, at least partly due to a paucity of early-intervention research. The aim of this Blood Pressure Postpartum (BP²) sub-study is to assess women's cardiovascular health at 6-months and 12-months after a HDP.

Methods: BP², a multicentre randomised controlled trial being undertaken at six Sydney hospitals, compares three follow-up/lifestyle behavioural change interventions that focus on CVD risk reduction from 6 (6 M) to 12 months (12 M) postpartum post-HDP. Assessment occurred at 6 M and 12 M postpartum: at both assessments, blood pressure (BP), anthropometric measurements and blood/urine samples were taken. Validated self-report questionnaires collected information about dietary intake and physical activity. Outcomes were compared between the overall cohort's 6 M and 12 M results (co-primary outcomes systolic BP and weight/waist circumference change), with categorical data compared through chi-squared testing and normally distributed continuous data compared through paired t-tests.

Results: At 31^st July 2021, 224 women had completed both 6-and-12-month postpartum BP² assessments (final n = 480). Average age at birth was 34.1 + 5.6 years; for 161 (71.9%) the index pregnancy was their first child, and 53.1%, 27.7%, 12.5% and 6.7% respectively had preeclampsia, gestational hypertension, chronic hypertension, and preeclampsia superimposed on chronic hypertension as their HDP.

Baseline (6 M postpartum) BP averaged 123 ± 13/ 81 ± 10 mmHg; 12 M average was 122 ± 12/ 80 ± 10 mmHg, with a mean difference in systolic BP of 1.4 ± 10.1 mmHg (p = 0.04) and diastolic BP of 1.4 ± 8.3 mmHg (p = 0.01). Weight at 6 M and 12 M averaged 75.7 kg ± 18.2 kg and 75.2 kg ± 18.6 kg respectively (p = 0.036), waist circumference 92.6 ± 16.0 cm and 91.9 ± 17.0 cm (NS), and BMI 27.9 ± 6.3 and 27.7 ± 6.5 (NS).

Conclusion: Findings suggest that the major assessed indicators for cardiovascular health (BP, weight, waist circumference and BMI) improve for all women with a history of HDP from 6 months to 12 months postpartum. While improvements are slight, further analysis once study sample size is reached will ascertain whether results are clinically relevant and if so, which studied postpartum lifestyle intervention is most effective.

8: C-type natriuretic peptide relaxes omental arteries in a new ex vivo model of preeclampsia

Bianca R Fato^2,1, Natasha de Alwis^2,1, Sally Beard^2,1, Adrian J Hobbs³, Tu'uhevaha J Kaitu'u-Lino^2,4, Kristen J Bubb⁵, Natalie J Hannan^2,1,4

1. Therapeutics Discovery and Vascular Function Group, Heidelberg, Victoria, Australia

2. Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia

3. Queen Mary University of London, London, England

4. Mercy Hospital for Women, Heidelberg, Victoria, Australia

5. Department of Physiology, Monash University, Clayton, Victoria, Australia

Background: Preeclampsia is a serious condition of pregnancy, associated with widespread maternal vascular and endothelial dysfunction. C-type natriuretic peptide (CNP) contributes to vascular homeostasis via endothelium-dependent vasorelaxant activity, acting specifically through NPR-C receptors; the role of CNP in preeclampsia is unknown. This study characterises the expression of CNP by the placenta from both control and preeclamptic pregnancies, and investigates whether CNP is able to dilate maternal arteries in several ex vivo models of preeclampsia.

Methods: CNP expression was assessed in placental tissue from preeclamptic (preterm n = 73; term n = 5) and normotensive pregnancies (preterm n = 13; term n = 44) via qPCR. Human omental arteries were dissected from omental fat biopsies, collected from normotensive pregnancies at term elective caesarean section (n = 16). Maternal serum was obtained from pregnancies complicated by preterm preeclampsia (requiring delivery <34 weeks, n = 9). Using wire myography, we investigated the effects of CNP on omental artery dilation as follows. Omental arteries were pre-constricted with preeclamptic serum, or recombinant endothelin-1 (ET-1; potent vasoconstrictor high in serum of preeclamptic patients), to model the systemic vasoconstriction associated with preeclampsia. Pre-constricted arteries were then treated with synthetic CNP (0.001–100uM), or vehicle control, and vascular relaxation assessed. In further studies, arteries were preincubated with the NPR-C antagonist, M372049 (10uM), for 30 min prior to serum-induced constriction and treatment with CNP, to investigate the mechanistic CNP/NPR-C signalling within the model.

Results: CNP mRNA was detectable in the human placenta; mRNA expression was not altered in preeclamptic pregnancies compared to controls (both preterm and term). Omental arteries pre-constricted with preeclamptic serum demonstrated significantly enhanced vasorelaxation when treated with synthetic CNP, compared to vehicle control, at doses 3.16uM-100uM. Additionally, CNP increased maximum arterial vasorelaxation, compared to control. Of note, addition of the NPR-C antagonist did not block CNP-induced relaxation in this model. Interestingly, synthetic CNP did not significantly dilate omental arteries pre-constricted with recombinant ET-1, compared to the control.

Conclusion: CNP directly stimulates maternal artery vasorelaxation in an innovative model of preeclampsia where constriction is driven by serum-derived soluble factors. However, we demonstrate its actions are not likely to be attributed to signalling via the NPR-C receptor, nor via ET-1 driven constriction pathways. CNP expression is not altered in placenta from preeclamptic pregnancies; further studies are required to investigate the expression of CNP and its receptors within the preeclamptic maternal vasculature. These data collectively suggest enhancing CNP could offer a potential therapeutic strategy for reducing systemic maternal vascular constriction in preeclampsia.

9: Peripheral blood inflammatory gene biomarkers and clinical factors can predict pregnancy induced hypertension and pre-eclampsia in people with asthma

Vanessa E Murphy¹, Fleur Nijdam², Evan Williams¹, Annelies L Robijn¹, Megan E Jensen¹, Peter G Gibson¹, Katherine J Baines¹

1. The University of Newcastle, Callaghan, NSW, Australia

2. University of Groningen, Groningen, The Netherlands

Background: Asthma is the most common chronic disease during pregnancy and associated with adverse perinatal outcomes including preterm birth, low birth weight, pregnancy induced hypertension (PIH) and pre-eclampsia (PE). Both asthma and PE involve inflammatory mechanisms, however, there is little known about the mechanisms involved in the development of PIH or PE in people with asthma during pregnancy. In this novel prospective study, we aimed to determine whether a blood inflammatory gene signature in mid-pregnancy was associated with the later development of PIH or PE among pregnant people with asthma.

Methods: Peripheral blood was collected into PAXgene Blood RNA tubes from pregnant people with asthma at 12–23 weeks gestation (n = 133). PIH and/or PE were defined as systolic blood pressure ≥ 140 mm Hg and/or systolic blood pressure ≥ 90 mm Hg after 20 weeks gestation, with proteinuria occurring in PE. All participants were normotensive at the time of blood collection. RNA was extracted using standard protocols and inflammatory gene expression was measured as mRNA counts using the NanoString nCounter Inflammation panel of 255 genes, and analysed for differential expression between groups (PIH/PE, no PIH/PE). Significant differentially expressed genes were assessed for prognostic ability (both individually and in groups with and without additional clinical features) using logistic regression modelling and calculation of the area under the receiver operating characteristic curve (AUC of the ROC). Networks of genes were investigated using the Search Tool for the Retrieval of Interacting Genes (STRING) database, applying a medium score of confidence (>0.4).

Results: Of the 133 women in the study, 14 were diagnosed with PIH/PE. In the PIH/PE group, 6 genes were expressed at significantly lower levels compared to the control group (LIMK1, MAFG, MAPK3, MEF2D, NFKB1, RELA, fold change −1.27, −1.27, −1.10, −1.18, −1.16, −1.12 respectively) and 4 of these genes were connected in 1 network (MAPK3, MEF2D, NFKB1,RELA). The 4 gene signature of MAFG, MAPK3, MEF2D and RELA, in combination with BMI, age, smoking status and parity of the childbearing parent, significantly predicted PIH/PE during pregnancy (AUC = 81.2%, p = 0.0169).

Conclusion: Our 4 gene signature and clinical marker model was predictive of PIH/PE in pregnant people with asthma and may therefore be useful in the clinic. Further research is needed to explore the mechanisms involved in the development of PIH and PE in pregnant people with asthma.

10: Metabolic outcomes in women six months and two years after hypertensive versus normotensive pregnancy – a P4 sub-study

Yamema Esber^1,2, Megan L Gow^1,3,4, Lynne M Roberts^2,3, Sathia Sushil^1,2, Gregory K Davis^1,2,3, Mark A Brown^2,5, George Mangos^2,5, Franziska Pettit^2,5, Tony O'Sullivan^2,6, Amanda Henry^1,2,3

1. Discipline of Women's Health, School of Clinical Medicine, UNSW Medicine and Health, Sydney, NSW, Australia

2. St George and Sutherland Clinical Campus, School of Clinical Medicine, UNSW Medicine and Health, Sydney, NSW, Australia

3. Department of Women and Children's Health, St George Hospital, Sydney, NSW, Australia

4. The University of Sydney Children's Hospital Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia

5. Department of Renal Medicine, St George Hospital, Sydney, NSW, Australia

6. Department of Endocrinology, St George Hospital, Sydney, NSW, Australia

Background: Preeclampsia and gestational hypertension (GH) are associated with increased long-term cardiovascular disease risk. However, few studies have investigated the influence of lifestyle factors, body composition and metabolic dysregulation on cardiometabolic risk in the early postpartum years, contributing to suboptimal postpartum management. Our prior work found increased insulin resistance and fat mass, and more sedentary lifestyle, six months after preeclampsia versus normotensive pregnancy. Consequently, this study aimed to: 1) Compare body composition, metabolic markers, energy expenditure and diet two years after hypertensive versus normotensive pregnancy, and 2) Examine how these measures changed from six months to two years postpartum.

Methods: This metabolic sub-study of the longitudinal Postpartum Physiology, Psychology and Paediatric cohort study assessed women at six months and two years after normotensive (n = 118), preeclamptic (n = 47) and GH (n = 14) pregnancies. Assessed measures included anthropometric measurements, body composition via bioelectrical impedance analysis, serum biochemical markers, 24-h energy expenditure using SenseWear Armbands and energy intake via a three-day food recall diary.

Results: At two years postpartum, post-preeclamptic women had significantly higher weight (median 67.1 kg versus 63.1 kg, p = 0.04) and LDL cholesterol levels (2.67 ± 0.78 mmol/L versus 2.41 ± 0.64 mmol/L, p = 0.03) compared to normotensive women. Women after GH had significantly higher weight (median 77.8 kg versus 63.1 kg, p < 0.001), percent fat mass (43.1 ± 7.7% versus 34.2 ± 9.3%, p = 0.001), triglyceride and insulin levels, and HOMA-IR score, and lower HDL cholesterol levels compared to normotensive women. In the subgroup of women for whom energy expenditure (n = 32, 23 post-normotensive pregnancy and 9 post-preeclampsia) and energy intake (n = 26, 18 post-normotensive pregnancy and 8 post-preeclampsia) was available, no significant differences were noted after standardising for fat mass. From six months to two years postpartum, total cholesterol levels and percent fat mass improved for all groups, while HDL cholesterol levels deteriorated for normotensive and post-preeclamptic women.

Conclusion: Two years after hypertensive pregnancy, women remain at greater metabolic risk than their normotensive counterparts, with greater weight, fat mass and metabolic dysregulation potentially contributing to future cardiovascular morbidity. Thus, the efficacy of targeted lifestyle modification programs in improving health outcomes for these women should be investigated.

11: Living with CF and raising a family - the new normal?

David A Stock ¹

1. Royal Hobart Hospital, Mount Stuart, TAS, Australia

Until 30 years ago, the expectation for a patient with cystic fibrosis was for them to struggle into late adolescence or early adulthood. Females were particularly prone to an accelerated decline and early death. Since then, however, advances in CF care have resulted in a dramatic improvement in life expectancy. Contraception and family planning have already become a routine part of CF care and we are seeing increasing numbers of pregnancies with successful outcomes for both mother and child, a trend which is likely to continue into the future, especially with the relatively recent advent of CFTR modulator therapy, which promises long-term disease modification with further reductions in morbidity and mortality. Establishing links between CF units and local obstetric services is, therefore, an important part of modern multidisciplinary care.

I will present an update on cystic fibrosis management, referencing opportunities and challenges in the field of feto-maternal medicine

12: The impact of Multiple Endocrine Neoplasia type 1 on reproductive health

Michael Thompson^1,2, John Burgess^3,1

1. Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart

2. Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia

3. School of Medicine, University of Tasmania, Hobart

Multiple Endocrine Neoplasia type 1 (MEN 1) is an autosomal dominant condition characterised by the development of multiple endocrinopathies. These include primary hyperparathyroidism, pituitary adenomas and gastroenteropancreatic neuroendocrine tumours, among others. These neoplasms often develop prior to reproductive years and may impact reproductive health. The data regarding the impact MEN 1 on reproductive outcomes was limited to two case reports prior to our work. The Tasman 1 MEN 1 kindred is the largest MEN 1 kindred globally with over 2500 descendants of a common ancestor across 9 generations. We examined the impact of MEN 1 on (1) fertility, (2) pregnancy and peripartum outcomes and (3) neonatal outcomes within the Tasman 1 kindred. We additionally present data on MEN 1-associated primary hyperparathyroidism, the evolution of hypercalcemia across pregnancy and its impact.

13: Replanting the Birthing Trees: transforming intergenerational trauma to reinforcing cycles of nurturing and recovery

Shawana Andrews ¹

1. The University of Melbourne, Parkville, VIC, Australia

A brief presentation of the Replanting the Birthing Trees project which combines Indigenous ways of knowing, being and doing with rigorous Indigenous-led research and practice evidence to implement and evaluate community-led continuity-of-care for the first 2000 days with seven perinatal services in two jurisdictions (Western Australia and Victoria), and concurrently build infrastructure for sustainable service delivery.

14: Indigenous data sovereignty and obstetric medicine

Jacob Prehn ¹

1. University Of Tasmania, Hobart, TAS, Australia

This presentation focuses on the Australian context, exploring the topics of Indigenous Data Sovereignty and Indigenous Data Governance and challenges field of Obstetric Medicine to operationalise these concepts within their research. Globally the Indigenous Data Sovereignty movement is a powerful force positively reshaping the Indigenous research landscape. A central ambition of the movement is the centring of Indigenous priorities and needs over the usual practice of prioritising the wants of non-Indigenous institutions, policy entities, and researchers. The sought result is a reduction of BADDR data-based research1: that is data that leads to blaming, is aggregated, is decontextualised, has a deficit focused, and is restricted for Indigenous analysis and publications. Yet while the Indigenous Data Sovereignty movement has been remarkably successful in raising awareness of Indigenous data rights, enactment of those rights within research has been harder to achieve. This presentation gives an overview of the Australian Indigenous Data Sovereignty movement and details Australia's obsession with BADDR data. I then provide a case study example of Indigenous Data Sovereignty and Indigenous Data Governance being operationalised in Australian research.

1. Walter, Maggie. “The Voice of Indigenous Data: Beyond the Markers of Disadvantage.” Griffith Review 60 (2018): 256–63.

15: Rising cases of syphilis in pregnancy and congenital syphilis: the time to act is now!

Sumudu Britton ¹

1. Royal Brisbane and Women's underline Hospital, Herston, QLD, Australia

In 2016, the WHO estimated that 1 million pregnant women were infected with syphilis. Syphilis in pregnancy is the second leading cause of stillbirth and is associated with a multitude of adverse pregnancy and neonatal outcomes. Australia has seen a rapid, and continued, rise in syphilis among women of reproductive age and during pregnancy since around 2015 which has resulted in an associated rise in cases of congenital syphilis. And yet, syphilis is easily diagnosed on serology, treatment with benzathine penicillin is safe and highly effective in pregnancy and treatment prior to delivery can prevent congenital syphilis. However, the ongoing challenges to identifying, diagnosing, engaging women in treatment and contact tracing their partners reflect the ongoing increase in cases of syphilis in pregnancy.

This talk will highlight some of the epidemiological features associated with syphilis in pregnancy, provide an update on criteria for testing and an overview of the essential features and challenges in the management of women with syphilis in pregnancy.

16: Improving pregnancy outcomes of indigenous women using the sFlt-1:PlGF test: a case report

Rebecca A Moorhead^1,2, Shaun Brennecke^1,2,3

1. Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia

2. Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia

3. Obstetrics & Gynaecology, The University of Melbourne, Parkville, Victoria, Australia

Introduction: Indigenous women in Australia have poorer pregnancy outcomes than their non-indigenous sisters. The sFlt-1:PlGF test helps predict placental dysfunction associated with preeclampsia and fetal growth restriction (FGR) and enables clinicians to improve surveillance of high-risk pregnancies.

Case Report: sFlt-1:PlGF testing was undertaken to improve the perinatal care of an indigenous woman with an extremely poor past obstetric history related to preeclampsia and FGR. The patient was a 34-year-old gravida 6 para 3 woman. Her history included two still births at 23- and 29-weeks’ gestation respectively and one neonatal death due to prematurity complications after delivery at 29 weeks, as well as two early pregnancy spontaneous miscarriages.

In her sixth pregnancy, the patient was referred for pregnancy care at 8 weeks gestation. She had no pre-existing hypertension or proteinuria, and no history of chronic kidney disease, anti-phospholipid syndrome or systemic lupus erythematosus.

She was commenced on low dose aspirin (150 mg nocte) with planned fortnightly outpatient review. At 13 weeks’ gestation, she had a Fetal Medicine Foundation (UK) preeclampsia risk evaluation, with a 1 in 2 high-risk result for the development of subsequent preeclampsia in her current pregnancy.

The sFlt-1:PlGF testing commenced at 21 weeks. Although the patient remained normotensive with no proteinuria, the sFlt-1:PlGF test results steadily increased from 27 at 21 weeks (normal <38) to 141 at 25 weeks. The patient was admitted with a diagnosis of preeclampsia at 25 weeks and 3 days. A growth and wellbeing fetal ultrasound was initially normal. Because of her poor obstetric history and evolving preeclampsia, corticosteroid loading for fetal lung maturation was administered and anti-hypertensive medication commenced. FGR was diagnosed at 26 weeks and 5 days, maternal blood pressure deteriorated, and booster corticosteroid dose was administered.

At 27 weeks, magnesium sulphate for fetal neuroprotection was administered and the patient underwent an emergency caesarean section for developing fetal compromise, delivering a baby girl weighing 718 grams. The mother progressed well postnatally. After 11 weeks of neonatal intensive care, the baby was discharged home weighing 2.27 kilograms.

Conclusion: This case illustrates how the sFlt-1:PlGF test can be used for high-risk pregnancy surveillance to help predict the onset of severe preeclampsia and FGR and improve pregnancy outcome in an indigenous woman. This case strengthens the argument for the sFlt-1:PlGF test to be more widely available to rural, remote and indigenous communities.

17: The Ngarrama Story: insights across the first 10 years of a continuity midwifery service for First Nations women and families

Michelle MO O'Connor¹, Sonita Giudice²

1. Metro North Hospital and Health Service - Royal Brisbane and Women's Hospitals, Brisbane, QUEENSLAND, Australia

2. Office of the Chief Nursing and Midwifery Officer, Department of Health, Bracken Ridge, Queensland, Australia

The Ngarrama midwifery group practice at the Royal Brisbane Women's Hospital commenced in 2012, after extensive community consultation, support and intentional co-design process. Metro North Elders named the service ‘Ngarrama’ which means ‘Calling the protective forces, the Birth Spirit which will protect the hopes, dreams and guardianship of our mothers and babies.” Ngarrama Maternity Services has grown, and collectively provided care for more than 3000 Aboriginal and / or Torres Strait Islander women and their babies over the past decade. A Ngarrama Elder has described the services as ‘Ngarrama Angels - as you are supporting our women and future generations by supporting traditional ways and importance of country”.

This presentation will share the principles and model which the Ngarrama service is founded within and also clinical outcome data from the Ngarrama service, showing closing the gap outcomes achieved, such as preterm birth, mode of birth and consumer perspective insight.

Michelle O'Connor

Midwifery Unit Manger

michelle.oconnor@health.qld.gov.au

18: Antimicrobial stewardship and sepsis prevention to improve maternity care

Shuyao Yan¹, Donna Lohmeyer², Angela Makris³, Amanda Henry^2,1,4, Kelly Thompson^4,5

1. Discipline of Women's Health, School of Clinical Medicine, UNSW Medicine and Health, Sydney, NSW, Australia

2. Department of Women's and Children's Health, St George Hospital, Sydney, NSW, Australia

3. Department of Renal Medicine, Liverpool Hospital, Sydney, NSW, Australia

4. The George Institute for Global Health, Sydney, NSW, Australia

5. Nepean and Blue Mountains Local Health District, Sydney, NSW, Australia

Background: Maternal sepsis is a life-threatening condition and the third most common cause of Australian maternal deaths¹. Antibiotics are essential for preventing and treating maternal infection and sepsis but rising rates of antimicrobial resistance (AMR) in hospital settings present a clinical conundrum in the absence of high-quality data on antibiotic stewardship in maternity units^2,3.

Objective: To determine the prevalence of and associated risk factors for the development of maternal infection and sepsis. To document antibiotic administration compliance with global and local recommendations and quantify AMR in Group B Streptococcus (GBS) positive women giving birth in a tertiary setting.

Methods: This was a retrospective observational cohort study using routinely collected maternity and pathology data from adult women giving birth at St George Hospital, New South Wales, between 1 January, 2018 and 31 December, 2020. Infection cases were defined as women with an identifiable cause of infection or pyrexia with a suspected infection. Sepsis cases were defined as women with infection and Sequential Organ Failure Assessment criteria ≥ 2. The primary outcome was the prevalence of maternal infection and sepsis. Secondary outcomes included maternal and neonatal factors associated with maternal infection and sepsis, incidence of and indications for antibiotic use and the prevalence of AMR in GBS positive women.

Results: 6954 women gave birth during the study period, of whom 151 (2.2%) had a documented diagnosis of maternal infection or sepsis. Overall, it was documented that women were given antibiotic prophylaxis less than 70% of the time when indicated. Maternal infection and sepsis were associated with an increased likelihood of ICU admission and stillbirth. Of 982 (14.1%) GBS positive cases, 40% of organisms were resistant to at least one antibiotic. In GBS positive women, there was no AMR to penicillin and ampicillin but AMR to erythromycin and clindamycin was greater than 30%. Women with infection/sepsis were also more likely to have a GBS antibiotic-resistant organism than those without.

Conclusion: Although antibiotics are essential for preventing and treating maternal infection and sepsis, current compliance with global and local guidelines was poorly documented. This presents an issue in evaluating the benefits of antimicrobial use compared to the known risks of rising rates of GBS resistance to erythromycin and clindamycin. Hence, there is a clear need for improved antimicrobial documentation in day-to-day practice and increased antibiotic stewardship to ensure quality of care in preventing maternal infection and sepsis.

1. World Health Organisation. Statement on maternal sepsis https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/matern alsepsis-statement/en/ (2017).

2. Rudd, K.E., et al. The global burden of sepsis: barriers and potential solutions. Critical Care 22, 232 (2018).

3. Bonet, M., et al. Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study. The Lancet Global Health https://doi.org/10.1016/S2214-109X(20)30109-1 (2020).

19: Biologics and advanced therapies for IBD in pregnancy

Britt Christensen

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract affecting both males and females, with a typical onset in young adulthood. This disease onset often coincides with the prime reproductive years of patients. Over the last several years, new treatments called biologics and small molecule therapies have become available for the treatment of inflammatory bowel disease (IBD) and other inflammatory diseases.These therapies are very effective at inducing and maintaining clinical remission in patients with IBD however many patients may be anxious about the effects of these medications on fertility and the safety of these medications during pregnancy and in breastfeeding. It is therefore imperative that both gastroenterologists and obstetricians are up to date regarding the safety of these medications in the pre- and post-conception stage and during breastfeeding. This talk will summarise the safety of current medications commonly used to treat IBD and discuss the role of disease monitoring, obstetrician and gastroenterology collaboration and the importance of maintaining disease remission to neonatal outcomes.

20: Pregnancy outcome in renal transplant recipients: a 21-year retrospective review

Jessica Han¹, Anna Krelle², Ciara McCormick¹, Paul Champion de Crespigny^2,3, Julia Unterscheider^1,4

1. Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia

2. Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia

3. Department of Medicine, University of Melbourne, Parkville, VIC, Australia

4. Department of Obstetrics & Gynaecology, University of Melbourne, Parkville, VIC, Australia

Introduction: Pregnancy in renal transplant recipients carries significant risks to the woman, infant and transplant and requires care by an experienced multidisciplinary team.

Aim and methods: The aim of our study was to describe rates of maternal, neonatal and renal complications in renal transplant recipients at a single centre in Metropolitan Melbourne. We conducted a retrospective cohort study of women who received a renal transplant prior to pregnancy at the Royal Women's Hospital, between 1 January 2000 and 31 December 2021. Women who had a pregnancy loss prior to 20 weeks were excluded from the study. Women were identified from the hospital database and individual patient medical records were reviewed for completeness of data points.

Results: The study included 31 pregnancies from 23 women. Six women had 2 pregnancies and 1 woman had 3 pregnancies including the only twin pregnancy (MCDA) observed in this cohort. One woman had a simultaneous pancreas-kidney transplant. Pregnancy rates increased dramatically over the 21-year study period, with 74% (23/31) of pregnancies managed in the past 10 years alone.

The mean maternal age was 32.9 years (range 28–41); 18 women (78%) had pre-existing hypertension and 2 women had pre-existing type 1 diabetes. The mean interval from transplantation to delivery was 8.8 years (range 2–19). Pre-eclampsia complicated over half (55%) of all pregnancies. Seventeen women (17/31; 55%) had an attempt at vaginal birth; 14 women had a pre-labour Caesarean delivery. The overall CS rate was 61% (n = 19) with 2 renal transplant injuries occurring at the time of birth. Mean gestational age at delivery was 34.2 weeks (range 20.0–40.4) with 69% (22/32) delivering prior to 37 weeks. The mean birth weight was 2140 g (range 456–3754) with over half of infants requiring admission to special or neonatal intensive care. The perinatal mortality rate was 125 per 1000 births including 2 stillbirths, and 2 neonatal deaths (MCDA twins).

There was a significant rise in creatinine levels pre-pregnancy and 3 months postpartum (102.10 vs 117.50umol/L). Graft loss, defined as either returning to dialysis or requiring transplantation, was not observed within a year of delivery; however, at time of follow-up, 2 women required a second transplant 3 and 9 years postpartum, respectively.

Conclusions: Our data demonstrate that pregnancies are increasingly common in renal transplant recipients. The main pregnancy complications were preeclampsia and preterm birth. Although graft loss was not observed within a year postpartum, baseline creatinine levels increased significantly after pregnancy.

21: Effect of antenatal prophylactic anticoagulation on labour and birth management and outcomes

Zaynab El-Hamawi^2,1, Antonia Shand^2,3, Giselle Kidson-Gerber^1,4

1. University of New South Wales, Sydney, NSW

2. Royal Hospital for Women, Randwick, NSW, Australia

3. Children's Hospital and Westmead Clinical School, University of Sydney, Sydney, NSW

4. Prince of Wales Hospital and Community Health Services, Sydney, NSW

Background: Prophylactic anticoagulation is used in the antenatal period to prevent venous thromboembolism in high-risk women. The most common anticoagulant used in pregnancy is enoxaparin, and its use in the peripartum period may pose potential challenges around labour and birth, including post-partum haemorrhage and neuraxial anaesthesia. There is a lack of uniformity in the peripartum management of women on prophylactic anticoagulation, including planned birth, neuraxial analgesia and/or change to unfractionated heparin in late pregnancy.

Aim: To determine the management and outcomes of women prescribed prophylactic enoxaparin during late pregnancy, including planned birth (caesarean section or induction of labour), access to and uptake of neuraxial analgesia, and birth outcomes.

Methods: Women attending the obstetric haematology clinics at Prince of Wales Hospital or the Royal Hospital for Women (RHW), or the RHW for antenatal care between 2014–2022 were included. Inclusion criteria included women on prophylactic enoxaparin during the pregnancy, who gave birth at or over 20 weeks gestation at RHW or Prince of Wales Private Hospital. For women who had more than one pregnancy during the time period, only the first pregnancy was analysed.

Results: Thirty-seven women were included in the analysis. The mean age was 34 +/- 5 years, mean gestation at birth 38 +/- 3 weeks, and mean BMI 23 +/- 4 kg/m². There were 22 (59.7%) nulliparous women. Overall 19 (51%) had a caesarean section (8 elective, 11 emergency). Of the 15 (40.5%) women who had an induction of labour, anti-coagulation timing was the indication for 7 (47%). Overall 22/34 (67.6%) women with data on neuraxial analgesia use, had an epidural or spinal anaesthetic. Of the 7 spontaneous labouring women with available data, 3 (43%) withheld their anticoagulation at the onset of labour symptoms, and 4 (57%) did not require specific management due to the timing of their last dose. There was no evidence of neuraxial analgesia being delayed or declined because of anti-coagulation. Of the vaginal births, there was one post-partum haemorrhage (>500 mL). Of the caesarean births, there were 4 post-partum haemorrhages (>1000 mL), one of which required blood transfusion.

Discussion: There were high rates of caesarean section and high rates of planned birth. There was no evidence of issues related to access to or as a result of neuraxial anaesthesia. There is no uniformity in management of anticoagulation. We have expanded the study to include two more sites to further evaluate pregnancy care and outcomes.

22: Effect of severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) Delta (B.1.617.2) variant on maternal and perinatal outcomes in the South-West Sydney population - a case control study

Luiza Peculis¹, Gauthami Bhagwanani¹, Alison Canty², Gaksoo Lee², Wendy Pickup², Roshika Kumar², Nilou Roshan Hesari², Angela Makris^2,3

1. Obstetrics and Gynaecology, Liverpool Hospital, Liverpool, NSW, Australia

2. Women's Health Initiative Translational Unit, Ingham Institute, Liverpool, NSW, Australia

3. School of Medicine, Western Sydney University, Penrith, NSW, Australia

Background: Covid-19 has been less prevalent in Australia than in some other nations but with the onset of the Delta (B.1.617.2) outbreak, rates of hospital and intensive care unit admissions increased rapidly. Data on previous SARS-CoV-2 strains established the relationship between infection and adverse maternal and perinatal outcomes including risk of preeclampsia, need for ventilation, preterm delivery and low birth weight¹⁻³. Despite a coordinated vaccine roll-out by the Australian Government, uptake by the pregnant population remained low. Our aim was to describe the maternal and perinatal outcomes of pregnant patients infected by SARS-CoV-2 Delta strain in the Southwestern Sydney population. The secondary objective was to assess the effect of vaccination against SARS-CoV-2 to maternal and perinatal outcomes.

Methods: We prospectively collected maternal and perinatal outcome data for pregnant women with confirmed SARS-CoV-2 infection by polymerase chain reaction (PCR) assay of nasopharyngeal swabs in the Southwestern Sydney Local Health district (SWSLHD) between June and October 2021. We compared demographic data to a cohort of pregnant women who delivered in 2018 (n = 4053).

Results: A total of 227 women tested positive for SARS-CoV-2 in SWSLHD; data of 197 patients was available for analysis. The two groups were similar in age (median 29.4 years vs 30 years, p = 0.07); the SARS-CoV-2 group had a higher BMI (median 26.92 kg/m² vs 24.8 kg/m², p < 0.001) and a higher proportion of women born in Australia (64% vs 41.3%). Asymptomatic/mild disease was the most common (80.7%; moderate 8% and severe/critical 11.3%). Most women were managed at home (59%), 10.8% in ambulatory care, 26.2% required admission and 4.1% required ICU admission. Invasive ventilation was required in 6% of those admitted, 47.8% required disease modifying therapies for moderate/severe infection. Miscarriage rate was 6%, stillbirth 1% and livebirth 95.5%. Rate of pre-eclampsia was 3.5%. The median gestational age at delivery was 39 weeks. The preterm delivery rate was 5.2%, all iatrogenic, and rate of small for gestational age 10%. Preterm delivery due to worsening maternal respiratory condition or concomitant severe preeclampsia was reported for 3% of the cohort. At this time, 84.5% of women were unvaccinated and thus analysis of the effect of vaccination was unreliable.

Conclusion: This large Australian cohort report of maternal and perinatal outcomes for pregnancies affected by Covid-19 Delta strain demonstrates that the maternal and neonatal outcomes are better than published data and may reflect the multidisciplinary approach in a well-resourced hospital in a first world nation.

1. Allotey, J., et al., Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ, 2020. 370: p. m3320.

2. Villar, J., et al., Maternal and Neonatal Morbidity and Mortality Among Pregnant Women With and Without COVID-19 Infection: The INTERCOVID Multinational Cohort Study. JAMA Pediatr, 2021. 175(8): p. 817–826.

3. Wei, S.Q., et al., The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis. Cmaj, 2021. 193(16): p. E540-e548.

23: Mental health of women with preeclampsia and normotensive pregnancy followed 2 years postpartum based on a prospective cohort study: postpartum, physiology, psychology and paediatric (P4) study

Jie Shang^2,1, Katie Harris¹, Maree Hackett^2,1, Mark Woodward¹, Lynne Roberts^3,4, Amanda Henry^2,1,3

1. The George Institute for Global Health, UNSW, Sydney, Australia

2. Discipline of Women's Health, School of Clinical Medicine, UNSW Medicine and Health, Sydney, Australia

3. Department of Women's and Children's Health, St George Hospital, Sydney, Australia

4. St George and Sutherland Clinical School, UNSW Medicine, Sydney, Australia

Background: Postpartum mental disorders, including depression, anxiety, and post-traumatic stress disorder (PTSD), have raised global concern and can lead to chronic adverse maternal and child health outcomes. Hypertensive disorders of pregnancy (HDP), affect 5–10% of pregnant women globally and are a leading cause of maternal mortality and morbidity. Associations between HDP and postpartum mental disorders are currently uncertain.

Study aim(s): To (i) investigate the prevalence of depression, anxiety, and PTSD at 2-years postpartum, after hypertensive versus normotensive pregnancy, (ii) compare the results with those at 6-month postpartum, (iii) establish a model predicting risk of any mood disorder.

Methods: Women that gave birth between 2013 and 2018 at St George Hospital, Sydney, Australia were recruited into the P4 prospective cohort study. Study visits were at 6-months, 2-years, and 5-years postpartum (ongoing). Demographic and pregnancy characteristics, maternal health and infant health were compared between women with normal blood pressure (NBP), gestational hypertension (GH) and preeclampsia (PE) at recruitment 6-months postpartum. Standardised scales were used for mental health disorder measurement: Edinburgh Perinatal Depression Scale (EPDS) for depression, General Anxiety Disorder-7 scale (GAD-7) for anxiety, Posttraumatic stress Diagnostic Scale (PDS)/PDS-5 for PTSD at 6-months and 2-years postpartum. Clinically significant cutoffs used were 10 and 12 for EPDS, 5, 10, 15 for GAD-7, and 15 for PDS/28 for PDS5.

Results: In total 365 women were followed at 2-year postpartum, including 271 NBP, 19 GH and 75 PE. The prevalence of women with any significant mental symptom was 10.4% at 2-years postpartum versus 9.9% at 6-month (depression: 9.3% versus 8.7%; anxiety: 3.8% versus 3.6%; PTSD: 0.3% versus 1%). Women in the GH group had a higher risk of having significant symptoms of anxiety (GAD-7 score>=10) versus normotensive women (15.8% versus 3.3%, p < 0.05), and women in the preeclampsia group were more likely to perceive childbirth as a traumatic event compared with women in the NBP group (8% versus 1.1%, p < 0.01). Women with presence of any significant mental symptom at 2-years postpartum was 9.6%, 26.3% and 9.3% (p = 0.09), for NBP, GH and PE respectively. Strong correlation was found between depression and anxiety scores at 2-year postpartum (r = 0.73).

Conclusion: HDP was not found to alter the risk of mental disorder symptoms at 2-years postpartum compared to women after normotensive pregnancy. However, symptoms of mental disorders occurring in the first months postpartum may persist through to at least 2-years.

24: Developing an understanding of the scope of the clinical utility of the sFlt-1/PlGF blood test in human pregnancy care

Shaun Brennecke ¹

1. Maternal-Fetal Medicine, Royal Women's Hospital, Parkville, Victoria, Australia

Human pregnancy disorders secondary to chronic placental dysfunction (CPD), such as preeclampsia (PE) and many cases of fetal growth restriction (FGR), are major causes of perinatal and maternal morbidity and mortality throughout the world.

The discovery of placenta-derived proteins, such as soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factor (PlGF), that reflect CPD and which circulate and are measurable in the maternal blood has been a major advance in facilitating the diagnosis and prognosis of CPD disorders.

In particular, circulating levels of sFlt-1 (which is increased in PE) and of PlGF (which is decreased in PE), when expressed as a ratio sFlt-1/PlGF, have been to shown to reflect the onset and severity of PE.

However, exploring the full extent of the clinical utility of the sFlt-1/PlGF blood test in human pregnancy care remains an area of current interest.

To this end, since introducing the test into routine clinical practice in 2016, the Department of Maternal-Fetal Medicine at the Royal Women's Hospital in Melbourne has maintained a database of sFlt-1/PlGF test results (now in excess of 8000) with associated clinical, laboratory and ultrasound information.

Based on analyses of the information in this database, it is becoming increasingly clear the sFlt-1/PlGF blood test has clinical utility in broad range of pregnancy care scenarios, in addition to monitoring the onset and severity of PE. These scenarios include monitoring the rate of deterioration in cases of PE, optimising maternal mental health in women with a poor past pregnancy outcome history, clarifying the differential diagnosis in PE-like conditions, diagnosing and managing idiopathic FGR, assessing for impending CPD at term with relevance to the associated timing and mode of delivery, and triaging women with suspected PE in terms of their requirement for ongoing inpatient versus outpatient care.

25: Labour and delivery outcome trends in mothers receiving kidney replacement therapy: analysis of linked ANZDATA Registry and Perinatal datasets over 22 years.

Nishanta Tangirala^1,2, Erandi Hewawasam^3,4, Chris Davies ^3,4, Zhouyang Li ⁵, Elizabeth Sullivan⁵, Amanda Poprzeczny ¹, Stephen McDonald ^2,3,4, Shilpa Jesudason^2,4

1. Women's and Children's Hospital, North Adelaide, Hackney, South Australia, Australia

2. Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia

3. Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia

4. Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia

5. Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia

Background: Delivery outcomes in the Australian pregnant dialysis and transplant population are unknown. Aim: We present the first Australian contemporary data on antenatal labour and delivery outcomes for women receiving kidney replacement therapy (KRT; chronic dialysis or kidney transplantation) compared to non-KRT cohorts. Methods: Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) was linked to perinatal datasets (all births ≥20 weeks’ gestation) in four Australian states from 1991–2013. Delivery outcomes were analysed between three cohorts: non-KRT, dialysis and renal transplant. Results: We assessed a total of 2,903,135 births (1,627,408 mothers) representing 50% of all births in Australia. There was a > 95% live birth rate across all three cohorts (p < 0.001). All babies born to women receiving KRT were born in a hospital or a birth centre. Women on KRT had low rates of spontaneous labour (29.5% dialysis vs 25.7% transplant vs 59.3% non-KRT; p < 0.001), with majority undergoing planned delivery with no labour (51.4% dialysis vs 45.5% transplant vs 15.1% non-KRT; p < 0.001). Caesarean delivery (CD) rates were significantly higher in the KRT cohort, accounting for >60% of all deliveries, compared to 26.4% of non-KRT (p < 0.001). Over time, CD rates have increased across all three cohorts, although more rapidly in the dialysis cohort. Diabetes and hypertension as reason for induction were higher in the KRT cohort (20% dialysis vs 31.3% transplant vs 18.1% non-KRT; p < 0.001). Post-partum haemorrhage and foetal distress were also more common (p = 0.006 and p = 0.001 respectively). Of concern, a significant proportion of the dialysis and transplant cohort underwent delivery with general anaesthesia (35% dialysis vs 9.6% transplant vs 3.5% non-KRT; p < 0.001). A breech presentation was more common in the KRT cohort likely due to higher rates of preterm birth. Conclusion: Women on KRT have higher risk deliveries and more birth interventions. Trends in rising caesarean deliveries in dialysed and transplanted women may be as clinicians counsel women for elective caesarean deliveries. Expected labour and birth outcomes underpinned with existing evidence must be clearly articulated to women with kidney disease or kidney failure earlier in pregnancy planning and their antenatal care to guide their choices and decision-making.​

1. Hewawasam E, Davies CE, Gulyani A, Li Z, Clayton PA, Sullivan E, McDonald SP, Jesudason S. Factors influencing fertility rates in Australian women receiving kidney replacement therapy: analysis of linked Australia and New Zealand Dialysis and Transplant Registry and perinatal data over 22 years, Nephrology Dialysis Transplantation, 2021; 37(6): 1–10.

2. Hewawasam E, Gulyani A, Davies CE, Sullivan E, Wark S, Clayton PA, McDonald SP, Jesudason S. Parenthood and pregnancy for end stage renal disease: protocol of national study of perinatal and parental outcomes through population record linkage. BMJ Open, 2020; 10(5): 1–7.

3. Hewawasam, E., Davies, C. E., Li, Z., Clayton, P., Sullivan, E., McDonald, S. P., & Jesudason, S. (2022). Determinants of Perinatal Outcomes in Dialyzed and Transplanted Women in Australia. Kidney International Reports, 7(6), 1318–1331.

26: An umbrella review of systematic reviews for the prevention of cardiometabolic conditions during pregnancy

Wai Kit Lee¹, Michelle Shi Min Ko², Yuanting Grace Li³, Lisa Chau Tran³, Elaine Osei-Safo⁴, Stephanie Cowan⁴, Frances Taylor⁴, Siew Lim³, Lisa Moran⁴

1. Faculty of Medicine, Monash University, Clayton, Victoria, Australia

2. Faculty of Medicine, Duke-NUS Medical School, Singapore

3. Monash University, Clayton, Victoria, Australia

4. Monash Centre for Health Research and Implementation, Monash University, Clayton, Victoria, Australia

Introduction: Certain pregnancy-related conditions indicate an increased risk of heart disease later in life for women such as gestational diabetes (GDM), hypertensive disorders of pregnancy (HDP), spontaneous preterm birth (PTB) and intrauterine growth restriction (IUGR). Intervening to reduce the risk or severity of these pregnancy-related conditions may reduce future risk of cardiovascular disease. (1) In this umbrella review, we documented the state of the literature on lifestyle changes in the prevention of these cardio-metabolic pregnancy conditions.

Methodology: A literature search from MEDLINE and CINAHL-PLUS was performed from the inception of the database until 24th of August 2021 for GDM, HDP, PTB and IUGR. Study selection, data extraction and quality appraisal of included papers were performed in duplicate. A narrative synthesis of the findings was conducted.

Results: We identified a total of 80 unique studies with 48, 36, 41 and 25 reviews respectively for GDM, HDP, PTB and IUGR. For GDM, dietary interventions such as the Mediterranean diet reduced GDM incidence while higher intake of unhealthy Western diets increased GDM incidence. Physical activity had mixed effects on GDM with exercise in the pre-conception or early pregnancy period and aerobic exercise having stronger evidence. With HDP, dietary interventions had less prominent effects, with only dietary patterns high in plant-based foods showing significant reduction on HDP occurrence. Exercise had varied effects on HDP, with aerobic exercise having contrasting evidence, leisure-time exercise benefiting only if done in sufficient intensity and prior to pregnancy and occupational activities such as lifting excessive weight and bending increasing pre-eclampsia incidence. For PTB, general dietary counselling and changes, as opposed to any specific diet, had significant effects in reducing PTB prevalence. There was no effect of physical activity changes on PTB. Regarding IUGR, energy/protein-balanced diets showed consistent reductions in SGA and LBW risk while any exercise had little effect. Occupational activities like heavy lifting were associated with an increased risk of PTB and IUGR.

Conclusions: There is a significant amount of research exploring the effect of lifestyle interventions for these cardiometabolic conditions in pregnancy. The current evidence supports the beneficial effects of both optimizing diet and physical activity consistent with population guidelines as well as specific changes to diets or physical activity such as increased uptake of healthier diets including the Mediterranean, energy-protein balanced and high vegetable intake diets for GDM, PTB and HDP prevention respectively, or avoidance of specific occupational activities for prevention of IUGR.

1. Parikh NI, Gonzalez JM, Anderson CAM, Judd SE, Rexrode KM, Hlatky MA, et al. Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association. Circulation. 2021;143(18):e902-e16.

27: StUdy of gestational diabetes and risk using electronic data (SUGARED)

Tessa Weir^1,2, Travis Stenborg³, Deborah Randall⁴, Tanya Nippita⁴, Sarah Glastras^1,2

1. University of Sydney, St Leonards, NSW, Australia

2. Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia

3. ARC Centre in Data Analytics for Resources and Environments (DARE), St Leonards, New South Wales, Australia

4. Women and Babies Research, Kolling Institute The University of Sydney Northern Clinical School Faculty of Medicine and Health, St Leonards, New South Wales, Australia

Background: Gestational diabetes (GDM) affects 1 in 6 pregnancies within Australia [1]. The incidence of GDM increased due to changed diagnostic criteria, implemented as a result of the Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study [2]. Bayesian methods are better at modelling complex data relationships compared to traditional methods of analysis. Hence, we reanalysed the HAPO data using Bayesian methods to identify subgroups of women with GDM with low or high risk of adverse outcomes.

Method: Bayesian regression analysis was applied to the HAPO dataset (> 23,000 women unclouded by treatment interference). This involved modelling birth outcome (birth weight >90th percentile) as a function of glucose levels on the 75 g oral glucose tolerance test and selected maternal variables (field centre, ethnicity, age and BMI), assuming a linear combination of fixed and random effects. Random intercepts and random slopes were associated with clusters in the maternal variables of interest.

Results: The model, including fasting, 1-h and 2-h glucose levels and selected covariates, predicted birth weight >90^th percentile. Change in each glucose measure's response as a function of the other two measures, with a single covariate, BMI, are seen in Figure 1. The model was then extended to include covariates field centre, ethnicity, age and BMI.

Figure 1: Mixed effects model. Estimated probability of birth weight > P90 by plasma glucose measures and BMI class

Conclusion: Our sophisticated statistical methods allow us to understand the complex inter-relationships between factors affecting adverse birth outcomes, and have established subgroups of women based on BMI and glucose levels at varying risk of birth weight >90th percentile. This model will be expanded to develop a personalised risk prediction tool, assisting clinicians and women to make more individualised decisions regarding treatment, thereby minimising unnecessary obstetric intervention and allowing for a focusing of resources on women at high risk of adverse outcomes.

1. O'Sullivan EP, Avalos G, O'Reilly M, et al. Atlantic Diabetes in Pregnancy (DIP): The prevalence and outcomes of gestational diabetes mellitus using new diagnostic criteria. Diabetologia. 2011;54(7):1670–1675.

2. HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002. doi:10.1056/NEJMoa0707943

28: Should we screen with a fasting blood glucose test? Modified gestational diabetes screening in the COVID pandemic - a large tertiary comparative cohort study

Jessica Deitch¹, I-Lynn Lee^1,2, Esha Kathpal¹, Christopher Yates^1,2, Cheryl Steele¹, Shane Hamblin^1,2, Bala Krishnamurthy^1,2,3, Joanne Said^1,2, Glynn Teale¹, Dev Kevat^1,4

1. Western Health, Melbourne

2. University of Melbourne, Melbourne, Victoria, Australia

3. St Vincent's Research Institute, Fitzroy, Victoria, Australia

4. Monash Health, Melbourne, Victoria, Australia

Background: The diagnosis and management of gestational diabetes mellitus (GDM) is resource intensive. National Australian prevalence was 15% in 2017 (AIHW), with rates of more than 22% currently reported by some centres. Consistent with COVID-19 guidelines, a modified diagnostic process was introduced at a Melbourne tertiary hospital with more than 6000 births annually and a multi-ethnic population. In place of screening with the conventional 75 g oral glucose tolerance test (OGTT), women underwent a fasting blood glucose (FBG). A result of >5.0 mmol/L denoted a diagnosis of GDM; patients with a FBG 4.7–5.0 mmol/L were offered an OGTT with standard diagnostic thresholds per IADPSG/ADIPS criteria; and patients with a FBG <4.7 mmol/L were not diagnosed with GDM and did not receive further testing.

Method: A retrospective cohort study comparing maternal and neonatal outcomes in 6451 women who had care under the modified diagnostic process with 8671 women who had GDM screening under the conventional approach was undertaken. Singleton pregnancies (n = 15,122) born from 20 weeks’ gestation at Western Health, Melbourne from 1/1/2019 until 31/3/2022 were included with births delivered from 1/7/20 until 31/12/20 excluded as a screening overlap period. The Birth Outcomes Database and medical records were accessed to retrospectively obtain maternal demographic data and perinatal outcomes.

Results: There was no difference in large-for-gestational age infant rate in the modified screening cohort compared to the conventional screening cohort (10.3% vs 9.4% (p = 0.06)). There was no difference in pre-term delivery rate (6.7% vs 6.4% (p = 0.45)) or gestational age at delivery (39.2 vs 39.1 weeks). Mean birth weight was slightly increased in the modified screening group (3334 g vs 3307 g) and small-for-gestational age infant rate reduced (9.2% vs 10.5% (p = 0.01)). Other neonatal outcomes including hypoglycaemia, respiratory distress and jaundice were similar between the different screening cohorts. GDM prevalence was similar between both groups (22.7% vs 22.2% (p = 0.43) and a reduced induction rate was found in the modified screening group (34.3% vs 39.8% (p < 0.01)). Rate of primary caesarean section rate was unchanged (18.4% vs 18.4% (p = 0.925)). In the modified screening group, the majority of women did not require an OGTT.

Conclusion: In a large high-risk multi-ethnic cohort, a modified approach had non-inferior outcomes to resource intensive conventional GDM screening.

Acknowledgements: Paul Lawton, Ibrahim Shahid, Daniel Garcia, and Thao Le for assistance with data gathering and categorisation.

29: Outcomes and management of pregnancy in women with myeloproliferative neoplasms

Cecily Forsyth ¹

1. Central Coast Haematology, North Gosford, NSW, Australia

Myeloproliferative neoplasms (MPN) are a group of hematopoietic stem cell-derived clonal disorders associated with an increased risk of thrombotic and haemorrhagic complications. Approximately 20% of patients with myeloproliferative neoplasma are under 40 years of age at diagnosis. Pregnant women with MPN are at increased risk of maternal thrombosis and haemorrhage and also of placental dysfunction resulting in pre-eclampsia, foetal growth restriction, pre-term delivery and foetal loss. The risks of pregnancy and the strategies used to improve outcomes will be discussed.

30: The management of transfusion-dependent thalassaemia in pregnancy

Giselle Kidson-Gerber ^3,1,2

1. University of NSW, Sydney, NSW

2. Department of Haematology, NSW Health Pathology, Randwick, NSW

3. Prince of Wales Hospital, Royal Hospital for Women, Randwick, NSW, Australia

Patients with transfusion-dependent thalassaemia require lifelong red cell transfusions for survival. This leads to iron overload, and further complications including cardiac disease, diabetes, hypopituitarism, hypothyroidism, osteoporosis and red cell antibodies. Many women with transfusion-dependent thalassaemia now conceive. The optimal management involves a multi-disciplinary team from pre-conception until post-partum. Current knowledge, local data and best practice of management of transfusion-dependent thalassaemia in pregnancy will be presented.

31: Perinatal Loss Midwifery Team: Providing more equitable, inclusive care coordination for families experiencing perinatal loss after 12 weeks gestation

Lisa McTavish¹, Anne Mariner ¹

1. Counties Manukau DHB, Manukau, AUCKLAND, New Zealand

Counties Manukau Health (CMH) is one of New Zealand's fastest growing DHB populations with approximately 7400 births occurring in a Counties Manukau facility during 2020. It is home to New Zealand's second largest Maaori population and largest population of Pacific people, as well as a fast-growing Asian community. Our population is diverse and vibrant with strong cultural values.

During 2021 CMH provided for @620 women experiencing perinatal loss from 12 weeks onwards. In late 2021, CMH had the opportunity to look at developing a new way to provide support to women and whanau experiencing perinatal loss within our service.

It hoped to change from the previously separate services which provided support for women dependant on gestation and to move towards developing a team with the remit to encompass support for all pregnancy loss from the second trimester onwards into one cohesive service.

This new team consists of two Specialist Perinatal Loss Midwives who provide support for all women and whanau experiencing pregnancy loss from 12 weeks gestation, whether through termination of pregnancy, miscarriage or stillbirth, as well as neonatal deaths up to 28 days of life. The team is supported by Obstetrics and Gynaecology Consultants and works closely with the associated Maternal and Fetal Medicine Team.

Key responsibilities of the team include, working in partnership with women, their whanau, and other health professionals to plan and co-ordinate care. Planning of any follow up postnatal care and review for women and their whanau who have experienced perinatal loss. Support staff with individual professional development needs as well as providing opportunities for staff debrief. Developing and facilitating multi-disciplinary training and education for staff relating to the care of women and whanau and perinatal loss. Planning, preparing and coordinating Women's Health Perinatal Mortality Meetings as well as the completing of PMMRC documentation acting as PMMRC Local Coordinators. The team in the future hope to also expand into the provision of post natal contraception for women prior to discharge from hospital.

This newly developed team hope to ensure that, whether a pregnancy loss is planned, or spontaneous and unexpected, women and their whanau feel that their individual values, beliefs and needs are met. That all women experience equitable and non-judgemental care and that they feel supported and respected and that their voices are heard.

32: Pregnancy outcomes in type 1 diabetes mellitus patients on haemodialysis at a large maternity centre

Razan Zein Isma^2,1, Greg Wilson^2,1

1. University of Queensland, Brisbane, Queensland, Australia

2. Department of Nephrology, Mater Hospital Brisbane, South Brisbane, Queensland, Australia

Background: The risk of maternal and fetal complications in women with type 1 diabetes mellitus (T1DM) and chronic kidney disease (CKD) is associated with the severity of CKD and degree of glycemic control. Current guidelines recommend early and frequent dialysis and good glycemic control to achieve the best possible pregnancy outcomes.

Case Report: We conducted a single center, retrospective case series from 2017 to 2021 of patients with T1DM with chronic kidney disease (CKD) who required dialysis during their pregnancy. Three patients with T1DM and CKD that required dialysis during their pregnancy were identified. Serum urea prior to commencing dialysis ranged between 11 to 18 mmol/L. Dialysis was initiated in one patient for refractory fluid overload and for elevated urea levels in two patients. Early and frequent dialysis was successful in maintaining urea level <12.5 mmol/L for all patients. All patients had both increased basal insulin requirements of 180–280% increase during pregnancy, and improved HbA1C levels from 8.7–14% in first trimester to 6.2–6.7% in third trimester, as pregnancy progressed. All patients achieved a live birth but only one out of the three patients achieved dialysis independence post-partum with a estimated glomerular filtration rate of 15 ml/min/1.73 m².

Conclusions: This case series highlights the importance of close monitoring and management of T1DM in pregnant women with CKD. Good glycemic control during pregnancy and early commencement of dialysis titrated to maintain urea levels below 12.5 mmol/L was successful in achieving live births in all patients in this study. This study also demonstrates that pregnancy in women with advanced kidney disease is likely to accelerate the commencement of maintenance dialysis.

1. Wiles, K., Chappell, L., Clark, K. et al. Clinical practice guideline on pregnancy and renal disease. BMC Nephrol 20, 401 (2019). https://doi.org/10.1186/s12882-019-1560-2.

2. Rudland, V.L., Price, S.A., Hughes, R., Barrett, H.L., Lagstrom, J., Porter, C., Britten, F.L., Glastras, S., Fulcher, I., Wein, P., Simmons, D., McIntyre, H.D. and Callaway, L. (2020), ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol, 60: E18-E52. https://doi.org/10.1111/ajo.13265.

33: Relationship of infant physical measures in the first year of life with the mother's gut microbiome in pregnancy: A MUMS sub-study

Aurora Upitis¹, Daniella Susic^2,3, Amanda Henry^2,3, Megan L Gow^2,3,4, Maria E Craig^2,3,4,5

1. University of New South Wales, Sydney

2. Women and Children's Health, St George Hospital, Sydney

3. School of Women's and Children's Health, University of New South Wales, Sydney

4. Westmead Children's Hospital Clinical School, The University of Sydney, Sydney

5. Institute of Endocrinology and Diabetes, Westmead Children's Hospital, Sydney

Background: Considering the long-term health outcomes associated with infant growth in the first year of life, understanding contributing factors is essential. This study aims to explore associations between the maternal gut microbiome and infant growth outcomes in the first year of life.

Methods: This is a sub-study of women (n = 100) in the Microbiome Understanding in Maternity Study (MUMS) cohort in Sydney, Australia. Maternal physical measures and fecal microbiome samples were taken at trimesters (T) 1, 2, and 3. The composition of the maternal gut microbiota was surveyed using whole metagenomic shotgun sequencing. Mode of delivery and development of pregnancy and labour complications were recorded. Infant anthropometric measures were recorded at birth, 6 weeks, 6 months, and 12 months. Statistical and bioinformatic analyses were undertaken using SPSS and Primer 7 respectively.

Results: T2 & 3 alpha diversity indices were positively correlated with infant growth outcomes. T3 beta diversity was associated with birth weight (p = 0.04). Relative abundance on genus and species levels were related to infant growth. T1 species Alistipes inops, Bifidobacterium pseudocatenulatum, and Bacteroides finegoldii were negatively correlated with infant growth outcomes, whilst Oscillibacter sp. PC13 and Christensenella minuta were positively correlated. T2 species Bacteroides plebeius and Prevotella corporis were negatively correlated with infant growth outcomes, whilst Roseburia sp. CAG:309 was positively correlated. T3 species Acidaminococcus intestine and Bifidobacterium dentium were negatively correlated with infant growth outcomes, whilst Eubacterium ramulus and Alistipes timonensis were positively correlated. Maternal factors (pre-eclampsia, gestational weight gain, and blood pressure) and mode of birth also impacted infant growth.

Conclusion: Within this limited sub-study correlations between the maternal microbiome and infant growth were detected, warranting further investigation on a larger scale controlling for post-natal factors. These results are significant due to the lasting health impacts of this window of development and may one day present an opportunity for early intervention.

34: The association between placental abruption and maternal cardiovascular outcomes

Dhnanjay Soundappan ¹

1. The University of New South Wales, Sydney

Introduction: Maternal placental syndromes have been previously demonstrated to lead to poorer long-term maternal cardiovascular health. However, the relationship between placental abruption and cardiovascular outcomes is relatively understudied.

Methods: This literature review examined the association between placental abruption and both cardiovascular morbidity and mortality.

Results: 11 cohort studies were examined following a review of relevant databases. 8 studies included cardiovascular morbidity as an outcome measure, most commonly defined based on a hospital admission related to cardiovascular disease. 6 studies included cardiovascular mortality as an outcome measure, most commonly measured from death registries using International Classification of Diseases codes. Women with a placental abruption were found to be at an increased risk of long-term cardiovascular morbidity and mortality. This risk is increased with multiple abruptions or severe placental abruption complicated by hypertensive disorders of pregnancy, small for gestational age babies, preterm birth, or perinatal death.

Conclusions: Placental abruption is associated with poorer maternal cardiovascular outcomes. Further research is warranted into the utility of early cardiovascular disease prevention in improving outcomes for women in this cohort of complicated pregnancies.

35: Anomalous systemic arterial supply to the basal segment of the lung presenting with haemoptysis in the third trimester of pregnancy

Kate Hawke¹, Kaustuv Joshi², Hervey Lau², Arani Halder^3,4,5, Petrina Duncan⁶, Penny Wolski¹

1. Department of Obstetric Medicine, Royal Brisbane & Women's Hospital, Brisbane, Qld, Australia

2. Department of Thoracic Medicine, Royal Brisbane & Women's Hospital, Brisbane, Qld, Australia

3. Department of Radiology, Royal Brisbane & Women's Hospital, Brisbane, Qld, Australia

4. Queensland Xray, Brisbane, Qld, Australia

5. The Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, Australia

6. Department of Obstetrics, Royal Brisbane & Women's Hospital, Brisbane, Qld, Australia

Anomalous systemic arterial supply to the basal segment of the lung (ABLL) is a rare congenital malformation. It is characterised by aberrant systemic arterial supply to the basal segment of the lung, with normal venous drainage to the pulmonary veins and normal bronchial branching. (1) ABLL may be complicated by massive haemoptysis, heart failure from left-to-right shunt, and infection. (2, 3) We describe a case of this condition presenting in the third trimester of pregnancy. To our knowledge this is the first case of a pregnant woman presenting with haemoptysis due to ABLL, managed post-partum with transarterial embolisation.

A 36-year-old woman in her first pregnancy presented at 35 weeks’ gestation to the emergency department of a tertiary obstetric centre with a four-day history of low-volume frank haemoptysis. CT chest angiogram demonstrated a wedge-shaped focus of consolidation in the posteromedial right lower lobe suggestive of pulmonary infarction. This pulmonary segment was supplied by a systemic artery arising from the aorta. There was a small rounded arterially-enhancing focus in the right lower lobe possibly representing an aneurysm in the systemic feeder artery. A multidisciplinary approach was necessary to determine treatment options, which ultimately consisted of elective caesarean section at 36 weeks and 4 days gestation, followed by a successful post-partum transarterial embolisation.

Changes to cardiac output and elevation of the diaphragm may be relevant to the presentation of this condition in pregnancy. Most published cases of related conditions presenting for the first time during pregnancy coincided with development of peak cardiac output in the second trimester, likely causing increased blood flow via the aberrant artery. (4–6) In our patient's case there was no haemoptysis until the 35^th week, making this mechanism unlikely the sole factor. In our patient the systemic arterial supply arose from the thoracic aorta at the level of the diaphragmatic crus. This may have resulted in mechanical compression of the arterial supply to the involved pulmonary tissue, leading to infarction and haemoptysis.

Regarding the mode of delivery, vaginal delivery with an unsecured aberrant arterial supply to the lungs has not been described. In our patient, the risks of labour, and the significant potential for an unsuccessful vaginal delivery requiring emergency caesarean section, prompted a decision to proceed with elective caesarean section.

While surgical resection has traditionally been the management modality of choice for ABLL, transarterial embolisation has been used in recent years in selected cases. (7)

1. Campbell DC, Jr., Murney JA, Dominy DE. Systemic arterial blood supply to a normal lung. JAMA : the journal of the American Medical Association. 1962;182:497–9.

2. Currarino G, Willis K, Miller W. Congenital fistula between an aberrant systemic artery and a pulmonary vein without sequestration. A report of three cases. The Journal of pediatrics. 1975;87(4):554–7.

3. Yabek SM, Burstein J, Berman W, Jr., Dillon T. Aberrant systemic arterial supply to the left lung with congestive heart failure. Chest. 1981;80(5):636–7.

4. Shaikh S, Saad RA, Christie G, Kerr KM, Remmen H. Spontaneous dissection of an anomalous systemic artery in the lung during pregnancy: a rare cause of hemoptysis. Ann Thorac Surg. 2006;82(2):725–6.

5. Freeman RK, Maxwell JM. Intralobar bronchopulmonary sequestration presenting as hemoptysis: evidence for an acquired cause. Mil Med. 1998;163(7):502–3.

6. Sayegh L, Greer M, Rabih F, Marts L. Pulmonary Sequestration Presenting as Hemoptysis in Pregnancy. American Journal of Respiratory and Critical Care Medicine. 2020;201:A3744.

7. Saida T, Ninomiya H, Hojo F, Nakayama M, Yamauchi T, Saida Y. Systemic arterial supply to the normal basal segments of the left lower lobe treated by coil embolization, with long-term follow-up. Radiat Med. 2006;24(5):365–8.

36: Meningioma presenting with severe neurological impairment during pregnancy: a case report

Kristen R Yeung¹, Svetha Rao¹, Tanushree Rao¹, Alan Adno¹, Ian Fulcher¹, Joanna Lee², Gauthami Bhagwanani¹

1. Obstetrics and Gynaecology, Liverpool Hospital, Liverpool, NSW, Australia

2. Neurosurgery, Liverpool Hospital, Liverpool, NSW, Australia

Background: Meningiomas are common neoplasms of the central nervous system¹. They are usually benign and slow growing, however accelerated growth of these tumours has been observed sporadically during pregnancy with an estimated incidence of 5–6 per 100 000 cases². This is most likely due to elevated sex hormone levels, although the pathogenesis remains unclear^3,4. Clinical features are non-specific and can be misinterpreted with common pregnancy symptoms. The presence of a tumour during pregnancy can be associated with significant complications including increased maternal morbidity, fetal growth restriction, and preterm delivery⁵.

This report describes a case of spinal meningioma in a twin pregnancy causing severe neurological impairment, poor mobility and recurrent falls requiring premature delivery and urgent surgical management.

Case Description: A 28 year old primiparous female was referred to the emergency department by her general practitioner with a several week history of loss of balance, dizziness and recurrent falls at 23 weeks gestation with dichorionic diamniotic twins. Initial work up included computerised tomography and magnetic resonance imaging (MRI) of the brain which were unremarkable. She was diagnosed with functional neurological disorder and discharged with outpatient neurology follow up.

She represented with progressive deterioration in neurological function including urinary incontinence and was wheel chair bound due to significant lower limb weakness causing recurrent falls. An MRI spine revealed a 10 × 10 × 20 mm, homogenous well defined extramedullary lesion at the T7 level, with associated cord compression. Differential diagnoses included meningioma and schwannoma. She underwent an uncomplicated elective caesarean section at 33 weeks gestation followed by T6 to T8 laminectomies and resection of the extramedullary lesion 48 h later. Her post-natal course was uncomplicated and her lower limb weakness gradually improved post operatively. Histopathology confirmed a meningioma (World Health Organisation Grade 1). Repeat MRI of the spine showed full resection of the lesion and she is currently undergoing rehabilitation as an inpatient.

Conclusion: Meningiomas are slow growing benign lesions that can in rare situations demonstrate rapid growth during pregnancy causing a range of neurological manifestations. Generally, there is minimal impact on maternal or fetal well-being, however, aggressive or highly symptomatic meningiomas require prompt identification and management as was demonstrated in our case due to poor mobility and recurrent falls due to spinal cord compression. This complex scenario requires a multidisciplinary team approach to ensure optimal maternal and fetal outcomes.

1. Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of meningioma. Journal of neurooncology. 2010, 99(3):307–14. doi: 10.1007/s11060-010-0386-3

2. Dumitrescu BC, Tataranu L.G., Gorgan M.R. Pregnant woman with an intracranial meningioma – case report and review of the literature. Rom. Neurosurg. 2014, 21: 489–496

3. Giraldi L, Lauridsen EK, Maier AD, Hansen JV, Broholm H, Fugleholm K, Scheie D, Munch TN. Pathologic characteristics of pregnancy-related meningiomas. Cancers 2021, 13, 3879. https://doi.org/10.3390/cancers13153879

4. Maiuri F, Montagnani S, Gallicchio B. Estrogen and progesterone receptors in meningiomas. Surgical Neurology 1986, 26: 435–440.

5. Molina-Botello D, Rodriguez-Sanchez JR, Cuevas-Garcia J, Cardenas-Almaraz BV, Morales-Acevedo A, Mejoia-Perez SI, Ochoa-Martinez E. Pregnancy and brain tumors; a systematic review of the literature. Journal of clinical neuroscience. 2021, 86: 211–216. doi: 10.1016/j.jocn.2021.01.048

37: Crigler Najjar type II and pregnancy

Katherine J Creeper¹, Dorothy F Graham^1,2

1. King Edward Memorial Hospital, Subiaco, WA, Australia

2. University of Western Australia, Perth, WA, Australia

Background: Crigler Najjar syndrome (CNS) is a rare condition associated with unconjugated hyperbilirubinemia. It is caused by mutations causing complete deficiency (type I) or severely reduced (type II) of the hepatic uridine diphosphoglucoronosyl transferase enzyme (UDPGT) which catalyses the conjugation of bilirubin with glucouronic acid within hepatocytes facilitating its excretion in bile. Evidence suggests that Crigler Nijjar is not associated with maternal risk, however, as unconjugated bilirubin is transported from the fetus to the mother across the placenta there is a risk of kernicterus and sometimes even death. Fetal unconjugated bilirubin levels often parallel those found in the mother. Phenobarbitone acts as an enzyme inducer and facilitates hepatic metabolism and excretion of bilirubin. Studies have shown that the administration of phenobarbitone antenatally is linked to reduced levels of serum bilirubin levels in the fetus and newborn.

Case: We report two consecutive pregnancies in a 29-year-old primigravida woman with Crigler Najjar Type II syndrome. Phenobarbitone therapy was commenced in the first pregnancy at 16-weeks’ gestation and was associated with favorable biochemical and clinical outcomes. There were no reports of long term neonatal neurological sequalae.

Conclusion: Pregnancy in Crigler Najjar syndrome is rare, with only a few reported cases. This case demonstrates the safety and beneficial effect of phenobarbitone therapy to both mothers and neonates.

38: Association between hydroxychloroquine and reduced risk of pre-eclampsia in Australian women with systemic lupus erythematosus

Jessica Phillips¹, Dorothy Graham¹

1. King Edward Memorial Hospital, Subiaco, Western Australia, Australia

Background: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that disproportionately affects women of child-bearing age. Although pregnancy outcomes for women with SLE have improved over time, the rates of pre-eclampsia and associated maternal and fetal complications remain significantly higher than in the general obstetric population.^1,2

Hydroxychloroquine (HCQ) use is associated with a reduced risk of flare in pregnant patients with SLE.^1,2 A recent meta-analysis of 1132 pregnancies reported a reduction in pre-eclampsia risk for patients taking HCQ, however this has never been examined in an Australian cohort.³

We aimed to investigate the association between HCQ use, risk of pre-eclampsia and neonatal outcomes in Australian women with SLE.

Methods: This was a retrospective study of women aged over 18 years with SLE who had one or more pregnancies managed at a tertiary centre in Western Australia between 2010 and 2020. The associations between HCQ use (as documented at booking antenatal visit or in correspondence from referring practitioners), pre-eclampsia and neonatal outcomes were examined using adjusted logistic regression models.

Results: There were a total of 95 pregnancies in 71 women, with 51 (53.7%) pregnancies exposed to HCQ. Women receiving HCQ were more likely to be dsDNA antibody positive, to have a higher median dsDNA level and to have detectable anticardiolipin antibodies. There was no difference between the two groups in terms of the clinical diagnosis of antiphospholipid syndrome or presence of other antiphospholipid antibodies. Women receiving HCQ were significantly more likely to be taking aspirin from less than 16 weeks gestation (80.4 vs 50%, p = 0.002).

11.8% of HCQ exposed pregnancies were complicated by pre-eclampsia, compared to 25% of pregnancies not exposed to HCQ (unadjusted OR 0.40, 95% CI 0.14–1.15). When adjusted for aspirin use, BMI, lupus nephritis, lupus flare in pregnancy and presence of antiphospholipid antibodies, HCQ use was associated with a significantly lower risk of pre-eclampsia (aOR 0.16, 95% CI 0.04–0.64) compared with non-HCQ use. There was no association between HCQ use and the neonatal outcome of gestation at delivery, special care nursery admission or birthweight in this cohort. Aspirin use was not associated with a decreased risk of pre-eclampsia, regardless of HCQ exposure.

Conclusion: When adjusted for confounding factors, HCQ use was independently associated with a lower rate of pre-eclampsia in women with SLE but had no impact on neonatal outcomes in this cohort.

1. Knight C, Nelson-Piercy C. Management of systemic lupus erythematosus during pregnancy: challenges and solutions. Open Access Rheumatology: Research and Reviews 2017:9 37–53.

2. Marder W. Update on pregnancy complications in systemic lupus erythematosus. Current Opinion Rheumatology 2019, 31:650–658.

3. Duan J, Ma D, Wen X et al. Hydroxychloroquine prophylaxis for preeclampsia, hypertension and prematurity in pregnant patients with systemic lupus erythematosus: A meta-analysis. Lupus 2021, Vol 30(7) 1163–1174.

39: The rate of hypertensive disorders in pregnancy and associated maternal characteristics in an Australian context

Grace Yuan¹, Helen McDougall², Nadia Olivier², David Langsford^2,1

1. The University of Melbourne, Parkville, VIC, Australia

2. The Northern Hospital, Epping, VIC, Australia

Background: Hypertensive disorders in pregnancy (HDP) affect around 5–10% of pregnancies and can have severe maternal and fetal complications. Understanding the prevalence of these conditions and patient characteristics in an Australian context may help inform future local guidelines and practices.

Aims:

1. To establish the rate of HDP at Northern Health.

2. To describe the characteristics of patients with HDP.

Methods: A retrospective audit of all deliveries was conducted at a level 5 maternity hospital (The Northern Hospital) between January 2016 and December 2020 using univariate and bivariate analysis. International Classification of Diseases (ICD) coding and Birthing Outcomes Summary (BOS) system data for each delivery was used and its validity was determined by data collected manually from the medical records of a randomly selected representative patient sample. These patient files were hand-searched for a documented HDP diagnosis to give a rate of HDP. Descriptive statistics were calculated for maternal demographics and comorbidities. Pearson's chi-squared test and one-way ANOVA tests were performed to identify a statistically significant difference when relevant.

Results: There were 17746 births from January 2016 to December 2020. The rate of HDP reported to general practitioners through discharge summaries generated by BOS was 4.7%. The rate obtained from the representative sample was 5.4% (36/669). Of HDP patients, 52.8% (19/36) had preeclampsia and 30.6% (11/36) had gestational hypertension. The prevalence of HDP over the 5 years was 5.5%, 3.8%, 4.0%, 4.7% and 5.4% (p = 0.001 for year-to-year comparison). Across the years, there were no differences in age (p = 0.067), BMI (p = 0.296) and prevalence of GDM (p = 0.453). There was a positive trend in the prevalence of antenatal aspirin use in these patients, increasing from 3.6% in 2016 to 11.9% in 2020 (p = 0.011).

Of the 17746 patients, 827 had a HDP diagnosis. HDP patients were on average 31.0 years old, had a BMI of 30.7 kg/m² and 27.4% (227/827) had GDM. Non-HDP patients were younger (29.8 years old, p < 0.001), had a lower BMI (26.8 kg/m², p < 0.001) and a lower proportion of GDM (21.0%, p < 0.001). The two populations had a similar distribution of Socioeconomic Indexes for Areas (SEIFA).

Conclusion: The established rate of HDP was on the lower end but consistent with other reported rates. Hand-searching files revealed under-reporting of HDP to primary care. Reflecting changing practice, there was increasing use of antenatal aspirin. Patients with HDP had characteristics known in literature to predispose to developing hypertension, including older age, higher BMI and GDM.

40: Clinical Conundrums: The challenges of distinguishing different causes of TMA in a pregnant renal transplant recipient

Pallavi Shamdasani¹, Anna Krelle², Sarah Price ^1,3, Mandy Law², Julia Unterscheider^4,5, Stefan Kane^4,5, Paul Champion de Crespigny^2,3

1. Department of Obstetric Medicine, Royal Women's Hospital, Parkville, VIC, Australia

2. Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia

3. Department of Medicine, University of Melbourne, Parkville, VIC, Australia

4. Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia

5. Department of Obstetrics & Gynaecology, University of Melbourne, Parkville, VIC, Australia

A 32yo G2P1⁻¹ kidney transplant recipient presented for maternity care. She had a history of end-stage kidney disease due to reflux nephropathy and had received a living-related kidney transplant in 2019. Three months pre-conception, acute T-cell mediated rejection was treated with pulsed steroids, with resolution of changes confirmed on follow-up biopsy. Her first pregnancy prior to transplant was complicated by severe pre-eclampsia (PET) and fetal growth restriction (FGR) resulting in a termination of pregnancy and subsequent neonatal death at 22 ^+ 1 weeks’ gestation.

Early antenatal history was unremarkable. Baseline blood pressure was 120/70 mmHg, creatinine 130umol/L. Medication included aspirin 100 mg d, azathioprine 100 mg mane, prednisolone 5 mg d, tacrolimus 6.5/6 mg bd.

At 20 ^+ 1 weeks, creatinine was rising (200umol/L); obvious precipitants (infection, obstruction) were excluded. Tacrolimus trough level was 5.8ug/L. Transplant biopsy showed new acute thrombotic microangiopathy (TMA) changes in one glomerulus and an arteriole. The sFlt-1/ PlGF ratio (PERT) was elevated at 90 suggestive of evolving early-onset PET. The tacrolimus dose was reduced and Labetalol 100 mg bd was commenced. Creatinine improved to 159umol/L.

At 22 ^+ 3 weeks, she was admitted for presumed HELLP. Blood pressure was 135/95 mmHg with sustained clonus. Investigations showed haemoglobin 86 g/L, platelets 131 × 10⁹, creatinine 180umol/L, haptoglobin <0.1 g/L and LDH 370U/L. However, the clinical picture was not entirely consistent hence alternative diagnoses were considered including TMA due to tacrolimus, atypical haemolytic uraemic syndrome (aHUS) and atypical PET.

At 22 ^+ 5 weeks, progressive hypertension (160/110 mmHg), thrombocytopenia (platelets 93 × 10⁹) and renal impairment were noted (creatinine 206umol/L). ADAMTS13 was normal. Antiphospholipid antibodies were negative. At his gestation, every effort was made to prolong the pregnancy. Following MDT discussion, treatment with eculizumab and high dose prednisolone was commenced, and tacrolimus was ceased.

Nocturnal hypertension remained problematic despite anti-hypertensive therapy. Renal impairment (peak urea 20.5 mmol/L, creatinine 235umol/L, urine protein-creatinine-ratio 163 mg/mmol) was progressive. Dialysis was commenced at 24 ^+ 1 weeks for fetal well-being.

At 24 ^+ 4 weeks, uncontrolled hypertension, progressive anaemia (60 g/L) and thrombocytopenia (36 × 10⁹) prompted delivery by classical caesarean section, resulting in the livebirth of a female infant weighing 538 g. At 4 weeks postpartum, infant and mother are well. Creatinine remains elevated at 180umol/L however she is not dialysis dependent.

This clinical conundrum explores the overlapping diagnostic features of pregnancy-associated TMA, aHUS and PET, and the options for therapeutic intervention in an attempt to prolong the pregnancy at a peri-viable gestation and balancing the risks of graft loss.

41: Water intoxication during labour: a maternal and fetal concern

Sarah A Gebara¹, Amanda Beech^1,2

1. Royal Hospital for Women, Randwick, NSW, Australia

2. Conjoint Clinical Lecturer, University of New South Wales, Kensington, NSW, Australia

Hyponatraemia is predominantly a disorder of water balance in which there is a relative excess of body water compared to total body sodium and potassium. Anti-diuretic hormone (ADH) is one of the main hormones responsible for maintaining water homeostasis in the body. ADH acts on the AVPR2 receptor in the collecting ducts of the nephrons of the kidneys leading to an increase in water reabsorption. An increase in osmolality, volume depletion, emotional stress, nausea, vomiting, and pain all stimulate the release of ADH. Oxytocin is structurally similar to ADH and mimics activity on the AVPR2 receptor.

Pregnancy is a state manifested by plasma volume expansion and sodium retention. Oestrogen and relaxin naturally released in pregnancy stimulate systemic vasodilation leading to a systemic arterial blood pressure decrease. This triggers the release of ADH causing water retention.

During labour, common symptoms of nausea, stress and pain stimulate the release of ADH. The natural release of oxytocin and administration of synthetic oxytocin also mimics the activity of ADH. This in addition to water intoxication through polydipsia and administration of intravenous fluids predispose the woman to hyponatraemia.

In recent years, there has been an increase in diagnosis of hyponatraemia in labour. This may be attributed to the above mechanisms as well as social encouragement of hydration in pregnancy and labour. We present the cases of five women who delivered in our tertiary unit and were diagnosed with hyponatraemia during labour or postnatally secondary to water intoxication. We review the acute management of these cases, along with the maternal and fetal outcomes.

42: Intrahepatic cholestasis in twin pregnancies: a population cohort study

Jessica A Marathe¹, Wei Lim How², Wendy Scheil³, Gustaaf A Dekker⁴, William M Hague⁵

1. Royal Adelaide Hospital, Adelaide, SA, Australia

2. Department of Obstetrics and Gynaecology, St Vincent's Hospital, Sydney, NSW, Australia

3. Pregnancy Outcomes Unit (retired), SA Health, Adelaide, SA, Australia

4. Department of Obstetrics and Gynaecology, Northern Adelaide Local Health Network, Adelaide, SA, Australia

5. Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia

Background: Intrahepatic cholestasis in pregnancy (ICP) is the commonest pregnancy-related liver disorder, and is associated with increased perinatal morbidity and mortality, particularly in instances where measured serum bile acids (SBA) are ≥100 mmol/L. There are limited data, however, on the management and outcomes specifically related to twin pregnancies affected by this condition. The aim of this study was to review all twin pregnancies affected by ICP over a 10-year period.

Methods: A retrospective cohort review of all pregnancies affected by antenatally-diagnosed ICP between the years 2000 to 2010 and managed in the public clinics at two major maternity hospitals in South Australia was undertaken and included all pregnant women with total SBA ≥10 mmol/L associated with pruritus (1). The data have subsequently been filtered to include women with only twin pregnancies. A detailed chart review of the twin pregnancies was undertaken, and included the collection of demographic data, and fetal and maternal outcomes and complications.

Results: 390 individual pregnancies were identified with ICP during the 10-year period, of which 24 were twin pregnancies. The median age of the women was 30 years, with a median BMI of 26.2 kg/m². Four women had a history of ICP during a previous pregnancy. The median gestation at ICP diagnosis was 33 ^+ 2 weeks. The median maximum SBA was 38 mmol/L, with two women having SBA >100 mmol/L. Thirteen women were treated with ursodeoxycholic acid alone, and one with both ursodeoxycholic acid and dexamethasone. Sixteen out of 24 women were delivered before 37 weeks. Three women had spontaneous onset of labour (34–37 weeks); nine women had labour induced: six birthing normally, three requiring emergency caesarean section; the remaining six women had elective caesarean section. Fourteen women (58%) experienced post-partum haemorrhage (PPH) (median blood loss 750 mL). The median birthweight was 2620 g, with median Apgar scores at 1 min and 5 min 8 and 9 respectively. Twenty-eight infants required admission to the special care nursery (SCN); two infants required admission to a level 3 neonatal intensive care unit (NICU) for issues associated with twin-to-twin transfusion. There were no stillbirths.

Conclusion: Twin pregnancies affected by ICP in our cohort were associated with high rates of preterm birth and induction of labour, with a high incidence of PPH. Infants were also more likely to require admission to a SCN/NICU. Further work is required to understand whether these outcomes can be modified in this subset of pregnancies that are affected by ICP.

1. Marathe JA, Lim WH, Metz MP, Scheil W, Dekker GA, Hague WM. A retrospective cohort review of intrahepatic cholestasis of pregnancy in a South Australian population. Eur J Obstet Gynecol Reprod Biol. 2017;218:33–8.

43: Echocardiographic or blood pressure screening of women with past pre-eclampsia and gestational hypertension: The western health survey of heart failure risk after pregnancy hypertension pilot survey (WHAT RISK)

Jonathan Sen¹, Jordan Dixon², Emma Smith², Sam Banks², Ashleigh-Georgia Sherriff¹, Lee-Anne Lynch², Leah Wright¹, Marc Oreto², Joanne Said², Tom Marwick^1,2

1. Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia

2. Western Health, St Albans, Victoria, Australia

Introduction: Pre-eclampsia (Pec) and gestational hypertension (GHT) are potential explanations for the female preponderance of heart failure with preserved ejection fraction. How and when to use this information clinically is unclear.

Hypothesis: We hypothesized that subclinical disturbances of left ventricular (LV) structure and function (stage B heart failure, SBHF) are more common at 5–10 years post-partum in women with a history of Pec compared with women with GHT or uneventful pregnancies.

Methods: The proportion of SBHF were compared between 25 women with Pec, 16 with GHT or normal pregnancy. Sub-group analysis comparing patients with and without hypertension at follow-up were also conducted.

Results: Among 41 participants (age 40 ± 6 years), followed at 9 years, SBHF was reported in 35% participants with Pec and 53% with GHT (p = 0.32). Diastolic blood pressure was significantly higher in patients with SBHF than without (94 ± 21 vs. 81 ± 13 mmHg, p = 0.035), and a similar trend was observed with systolic blood pressure (147 ± 42 vs. 128 ± 22 mmHg, p = 0.099). SBHF was observed in 6 (55%) of 11 pts with hypertension at follow-up, but only in 7 (32%) of 22 without (p = 0.27). Mean LV end-diastolic volume (117.2 ± 19.1 vs. 93.3 ± 13.1 mL, p = 0.03), LV end-systolic volume (51.9 ± 7.5 vs. 42 ± 7 mL, p = 0.04), LV mass index (73 ± 8.6 vs. 67.3 ± 14.6 mmHg, p = 0.41), E/e’ (Sept: 9.7 ± 2.7 vs. 7.5 ± 1.7, p = 0.009; Lat: 7.4 ± 2.6 vs. 5.5 ± 1.7, p = 0.02) were higher in participants with hypertension than without.

Conclusions: 9 years after pregnancy, SBHF was prevalent in pts with both previous Pec and GHT, but was not significantly different between the entities. Echocardiographic screening may add little to blood pressure follow-up in the identification of HF risk.

44: Essential thrombocytosis in pregnancy: A case report

Julie George ^1,2,3

1. Tan tock seng hospital, Singapore, SINGAPORE

2. Yong Loo Lin School of Medicine, Singapore, SINGAPORE

3. Maternal fetal medicine, KK women's and children's hospital Singapore, Singapore

Introduction: Essential thrombocytosis (ET)is a clonal myeloproliferative disorder which is usually discovered incidentally on routine testing and has a female predominance with a median age of diagnosis at 50 years. Although 25–30% patients are asymptomatic, pregnant women are at high risk of first trimester foetal loss of 30% with a live birth rate of 70%. Essential thrombocytosis with pregnancy imparts a hypercoagulable milieu, conferring a heightened risk for thrombosis. In addition, bleeding diathesis may escalate at the time of delivery and in the postpartum phase, especially in the context of treatment with aspirin and/or low molecular weight heparin (LMWH). Besides maternal complications such as intra-uterine growth retardation (IUGR) from preeclampsia or placental insufficiency need special considerations.

Case summary: 29-year-old female, smoker, BMI35 who had a one previous normal pregnancy was diagnosed with Essential thrombocytosis (ET), CALR + JAK2+, MPL exon10 wild type+, during her second pregnancy when her platelet counts were 588–655 x10⁹/L. The Ristocetin cofactor assay was 39%(50–130%). She was given Aspirin throughout the pregnancy and patient declined Bone marrow examination. She was asymptomatic except for intermittent headaches. She had full term normal vaginal delivery without complications, and she declined to take Clexane postpartum and defaulted her follow ups.

Subsequently she had 2 more pregnancies at 2-year intervals. Her platelet counts ranged from 1079–1260 x10⁹/L with occasional myelocytes on peripheral blood film. She had mild Anemia Hb:10 gm/dl, with variable leucocyte counts 10 −17 × 10⁹/L. She had intermittent headaches and peripheral numbness with rising platelet counts. Although based on her revised IPSET-thrombosis risk stratification she was considered low risk for thrombosis, she was offered cytoreduction with Interferon due to her symptoms and rising platelet counts which she declined. Hence, she was only on Aspirin for both her pregnancies and was advised Clexane postpartum for 6 weeks. She had uncomplicated pregnancies with induction of labor at full term with normal vaginal deliveries.

Conclusion: The management of ET in pregnancy is challenging due to the additional thrombotic risk that pregnancy confers along with the bleeding complications of extreme ET versus potential harm to the foetus. Cytoreductive therapy is based on revised IPSET-thrombosis risk stratification which has limited applicability in pregnancy. Interferon therapy is usually preferred due to its safety profile in pregnancy, however, there have been case reports of successful use of Anagrelide and Hydroxyurea during pregnancy.

1. Gangat Naseema, Tefferi Ayalew. Myeloproliferative neoplasms and pregnancy: Overview and practice recommendations.Am J Hematol. 2021;96:354–366.

45: Bromocriptine in recurrent peripartum cardiomyopathy: A case report

Maryon Jones¹, Suresh Vardarajan¹, Chiew Wong¹, Michele Bardin¹, Lucy McBride¹, Arzoo Khalid¹, David Langsford^1,2

1. The Northern Hospital, Epping, VIC, Australia

2. University of Melbourne, Melbourne, VIC, Australia

Background: Peripartum cardiomyopathy (PCM) is a condition associated significant morbidity and mortality. This condition affects 1:100–1:20 000 deliveries worldwide, with the highest incidence seen in the African subcontinent (1,2). PCM typically occurs within one month pre- or postpartum (3). Onset may be insidious and clinical features may initially be overlooked. Transthoracic echocardiogram and natriuretic peptide levels (BNP or NT-proBNP)) can assist in diagnosis (3). The cornerstone of management is reducing preload, afterload and optimising cardiac contractility with beta blockers, ACE inhibitors (post-partum), diuretics, and antiarrhythmics being the preferred pharmacological agents (3). Early delivery is indicated particularly in women with significant haemodynamic compromise.

There is emerging evidence that the breakdown product of prolactin plays a role in the pathophysiology of peripartum cardiomyopathy (3). Studies inhibiting prolactin secretion with the dopamine agonist bromocriptine have demonstrated efficacy in reducing mortality, morbidity and assisting left ventricular ejection fraction (LVEF) recovery in women with peripartum cardiomyopathy (3). Risk of recurrent cardiomyopathy can be as high as 20% in women with subsequent LVEF normalisation, and 50% in women with a persisting impairment (3). As such, optimising therapeutic strategies is imperative in managing women with this condition.

Case Report: This case discusses the management of the subsequent pregnancy in a 37-year-old female with history of postpartum dilated cardiomyopathy. Her previous pregnancy was characterised by a rapid development of biventricular failure (LVEF 19%) and cardiogenic shock two weeks postpartum requiring intensive care admission and inotropic support. Bromocriptine was utilised with subsequent normalisation of her ejection fraction.

Following a late referral, she was first reviewed at 22 weeks gestation whilst on perindopril, apixaban, ivabradine, spironolactone and frusemide (although with probable suboptimal compliance). Medications were adjusted following urgent cardiological review and she continued pregnancy on carvedilol with active surveillance including planned echocardiogram and NT-proBNP levels.

At 36 weeks gestation her NT-pro BNP rose >300 pg/mL and transthoracic echocardiogram (TTE) demonstrated a mildly dilated LV with moderate systolic dysfunction, LVEF 35–40%.

Delivery was brought forward, and she underwent a caesarean section at 36 + 4 gestation with concurrent tubal ligation. She was not breastfeeding due to other factors, so was treated with seven days of bromocriptine postpartum with subsequent normalisation of her NT-pro BNP and LVEF.

Conclusion: This case highlights the risk of recurrent peripartum cardiomyopathy in subsequent pregnancies and management strategies that can be implemented. Here, we demonstrated a real world application of utilising bromocriptine with a positive therapeutic outcome.

1. Isezuo, S.A. and Abubakar, S.A. (2007) Epidemiologic Profile of Peripartum Cardiomyopathy in a Tertiary Care Hospital: Ethnicity and Disease, 17(2): 228–233.

2. Kamiya, C.A. et al. (2011). Different characteristics of peripartum cardiomyopathy between patients complicated with and without hypertensive disorders. Results from the Japanese Nationwide survey of peripartum cardiomyopathy: Circulation Journal 75(8): 1975–1981

3. Davis, M. et al. 2020: Peripartum Cardiomyopathy: JACC State-Of-the-Art-Review, Journal of the American College of Cardiology.

46: Pregnancy-related liver disease is more common in aboriginal and Torres Strait islanders: Targeting an at-risk and unstudied population

Alexandra Fullerton¹, Richard Skoien^2,3, Helen Tanner^1,3

1. Obstetric Medicine, Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia

2. Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia

3. School of Medicine, University of Queensland, Brisbane, QLD, Australia

Background: Pregnancy-related liver disease (PRLD), such as intrahepatic cholestasis of pregnancy (ICP), pre-eclampsia and/or HELLP syndrome, acute fatty liver of pregnancy (AFLP), and hyperemesis gravidarum (HG), affect approximately 3% of pregnancies worldwide. Prevalence of each condition per pregnancy varies (≤0.1% for AFLP to up to 8% for pre-eclampsia/HELLP) and there is ethnic variation (ICP affecting 0.7% of European pregnancies but 4% of pregnancies in indigenous South Americans). There are no published data on the prevalence of PRLD amongst Australian Aboriginal and Torres Strait Islander mothers, despite recognised disparities in maternal health outcomes compared with the non-indigenous population. METHODS: This study aimed to quantify the prevalence and incidence of PRLD amongst indigenous women receiving antenatal care at Royal Brisbane and Women's Hospital. Data regarding patient demographics, pre-existing liver disease, co-morbidities and pregnancy outcomes were obtained from a dedicated semi-prospectively maintained maternity database. Significant associations were identified using Fisher's exact test (categorical variables) and the Mann-Whitney test (continuous variables). RESULTS: Data from 1302 pregnancies from July 2014 to June 2021 were analysed. Mean values (± standard deviation) were obtained for pre-pregnancy BMI (27.2 ± 8.5 kg/m2), maternal age at delivery (26.8 ± 6.1 years) and gestational age at delivery (37.6 ± 3.8 weeks). Smoking was common (43.5% up to 20 weeks, 33.0% after 20 weeks) but high levels of alcohol consumption was rare (1.8%). A total of 185 women (14.2%) were diagnosed with PRLD (7.0% eclampsia/HELLP, 6.6% HG, 1.4% ICP, 0.0% AFLP). The incidence of these conditions remained stable over the seven years. Pre-existing liver disease was diagnosed in 65 mothers (5.0%), with the majority having hepatitis C. A subsequent diagnosis of PRLD was more common in these patients (24.6% vs. 13.7%; P = 0.027). Mothers who developed PRLD had higher pre-pregnancy BMI (28.7 ± 9.4 vs. 27.0 ± 8.3 kg/m2; P = 0.017) and were more likely to have diabetes/gestational diabetes (22.7% vs 14.1%; P = 0.004) and hypertension (7.6% vs 1.7%; P = 0.0001). CONCLUSIONS: The prevalence of PRLD in Australian indigenous mothers was several-fold higher than the published international prevalence, while non-pregnancy-related liver disease was rarely diagnosed. PRLD was associated with higher BMI, diabetes/gestational diabetes, hypertension and pre-existing liver disease. These are the first data related to PRLD in Aboriginal and Torres Strait Islander peoples and further studies are warranted to improve outcomes in this vulnerable patient population.

47: In Vitro fertilisation-induced hypertriglyceridaemic pancreatitis

Katherine Wyld ¹

1. Redcliffe Hospital, Redcliffe, Queensland

A 35 year old G4P2M1 presented to the Emergency Department with severe abdominal pain and vomiting and was diagnosed with pancreatitis. Her serum was noted to be lipaemic and a lipid profile was performed revealing triglycerides of 172.5 mmol/L.

Medical background was significant for well-controlled type 2 diabetes (with a recent HbA1c of 6.5%), polycystic ovarian syndrome, subclinical hypothyroidism and dyslipidaemia. Regular medications included fenofibrate 145 mg daily, metformin XR 2 g daily, atorvastatin 80 mg nocte, thyroxine 75 mcg daily, Optisulin 50 units nocte and Novorapid 20 units TDS. Prior to planning pregnancy the patient's diabetes was controlled with semaglutide and metformin. The patient lived with her husband and 2 children and was a non-smoker. She drink minimal alcohol of less than 1 standard drink per week.

The patient had undergone an unsuccessful cycle of in vitro fertilisation (IVF) around 2 weeks prior to her presentation involving oestrodiol 6 mg, with a negative beta HCG a week prior to presentation. Of note, her triglycerides completed 2 months prior to her IVF cycle were normal at 1.1 mmol/L. Review of previous investigations demonstrated elevated triglycerides on external pathology in 2017, 2018 and 2019 correlating with previous pregnancies and IVF.

The patient was managed initially with an insulin infusion and was kept nil by mouth, with fenofibrate 145 mg continued. The insulin infusion was ceased when triglycerides fell below 10 mmol/L, and subcutaneous insulin was resumed. Fish oil 2 g BD was added to her therapy. Repeat triglycerides a month following her presentation were 2.8 mmol/L.

Hypertriglyceridaemia induced by high dose oestrogen therapy is a rare but recognised complication of in vitro fertilisation. Although the patient had a background of diabetes this was well controlled, and the significant and rapid elevation in triglyceride levels after her IVF cycle were highly suggestive that this was the acute precipitant. Proposed mechanisms include oestrogen-induced inhibition of lipoprotein lipase and increased hepatic triglyceride synthesis.

Future cycles of IVF and pregnancy would pose risk of recurrent severe hypertriglyceridaemia for this patient. She currently remains ambivalent about pursuing future pregnancy, but further IVF attempts would need to avoid high dose oestrodiol and close monitoring during pregnancy would be required. Further adjunctive therapies such as gemfibrozil may be required during pregnancy, and plasmapheresis could be considered in severe hypertriglyceridaemia.

48: ‘Beyond the Bump’: development, implementation, and evaluation of an online wellbeing and lifestyle pilot program for first year postpartum mothers

Hannah E Christie^1,2, Lauren A Roach^1,2, Monique E Francois^1,2

1. School of Medicine, University of Wollongong, Wollongong, NSW, Australia

2. Illawarra Health and Medical Research Institute, Wollongong, NSW, Australia

This project aimed to develop, implement, and evaluate the Beyond the Bump (BtB) postpartum pilot program to improve access to expert education on health and wellbeing, and support women to be more physically active in their first year postpartum. A three-stage mixed-methods design was used: (1) needs assessment through online focus groups and phone interviews to inform the design of the BtB program, (2) pilot study to implement the program (a ten-week series of live webinars) and assessment of health behaviours through a pre- and post-program survey, and (3) evaluation to seek feedback on the program through surveys or phone interviews of women who attended stage 2. Women in their first year postpartum participated in all three stages and postpartum primary care health professionals participated in only stage one. The needs assessment with 12 women and 16 health practitioners identified a strong need for an online postpartum program during COVID-19 that included access to postpartum professionals. Topics suggested for live webinars included support for returning to fitness and work, pelvic floor, babies first aid and sleep among others. The BtB online ‘live’ program was developed based on suggested needs and time-of-day ‘morning’, however, attendance to all ten sessions in the program was poor (23% of eligible women (n = 162) participated in first session and 5% in the last session). Barriers to attendance included ‘too busy’, ‘forgot’, and ‘topic not relevant for age of child’. 88% of women reported education as the most enjoyable part of the program, with 19% reporting physical activity as the most liked portion of the program. 100% of women interviewed would recommend the program to a friend. Cited barriers for non-attendance were factors that may be easily addressed in the future reiterations of BtB programs. More research is needed to improve the uptake and value placed on mothers’ level of physical activity and fitness. Future postpartum programs may benefit from integrating online platforms that are more flexible than a live webinar to improve attendance and separating 0–6- and 6–12-months postpartum topics to improve relevance.

49: Effectiveness of a nurse practitioner-led cardiovascular prevention clinic at reduction of metabolic syndrome following maternal complications of pregnancy: a preliminary analysis

Emily Aldridge^1,2, Maleesa Pathirana^1,2, Melanie Wittwer^1,3, Susan Sierp², Shalem Y Leemaqz⁴, Claire T Roberts^3,4, Gustaaf Dekker^1,5, Margaret A Arstall^3,2

1. Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia

2. Department of Cardiology, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia

3. Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia

4. Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, 5042

5. Division of Women's Health, Lyell McEwin Hospital, Elizabeth Vale, SA, Australia

Introduction: Maternal complications of pregnancy, including hypertensive disorders of pregnancy, gestational diabetes mellitus, intrauterine growth restriction, preterm birth, and placental abruption, are associated with increased risk of future cardio-metabolic disease. Lifestyle interventions that introduce preventative strategies for this young, high-risk population of women may assist in cardio-metabolic disease risk reduction. The aim of this preliminary registry analysis was to observe the change in maternal metabolic syndrome status after receiving a nurse practitioner-led lifestyle intervention delivered soon after a complicated pregnancy.

Methods: this preliminary analysis included 64 women who had attended both baseline (approximately six months postpartum) and review (approximately eighteen months postpartum) appointments at the postpartum intervention clinic after an index pregnancy complicated by at least one maternal complication of pregnancy. Metabolic syndrome status at both appointments was determined according to the International Diabetes Federation definition.

Results: At the baseline appointment, 22 (34.4%) women met the criteria for metabolic syndrome. This number reduced at the review appointment to 19 (29.7%). This difference was not statistically significant. There were also no statistically significant differences between cardio-metabolic risk factors between time points.

Conclusion: There was a high percentage of metabolic syndrome present early in the postpartum period. The results of this preliminary analysis highlight the importance of continuing preventative care and ongoing research for this group of high-risk women.

50: Usefulness and trustworthiness tool development and systematic review of 24 randomised controlled trials evaluating nifedipine for tocolysis

Ruxanda Rusu¹, Helen Vu¹, Ben W Mol¹

1. Monash Health, Clayton South, VIC, Australia

Introduction: Preterm birth has been a longstanding obstetric complication associated with increased mortality and morbidity. The aim of this study is to develop assessment tools that evaluate the quality of published data that inform hospital protocols. These tools will be tested via a systematic review of 24 randomised control trials (RCTs) on tocolytic interventions.

Methods: RCTs were selected from the most recent Cochrane review evaluating the effectiveness of tocolytics, specifically studies that included comparisons with nifedipine. General characteristics, results, and patient demographics were extracted from the original publications. Previously described quality assessment tools were used and adapted for the current study. Quality assessment included usefulness (the value of a study), trustworthiness (whether we can trust the data), and external validity criteria (whether the data are biased).

Results: We identified 24 RCTs. Nifedipine was compared to nine different tocolytics. In assessing the usefulness of the selected studies, we noted that many lacked a pragmatic study design. Only six (25%) of the assessed RCTs reported complete power calculations and were able to recruit sufficient participants to reach statistical power in the final sample size. Five studies (20.8%) recruited participants from more than one clinical centre. None of the studies asked for patient/participant input and no value for money calculations were reported.

Transparency, one of the usefulness criteria, was also a concern; four studies (16.7% CI95% [1.7–31.6]) were registered in a trial database (only one study registered prospectively), and no published protocols. Seven studies (29.2% CI95% [11–47.4]) disclosed funding disclosure, four studies (16.7% CI95% [1.7–31.6]) included comments on conflicts of interest, while none mentioned availability of raw data.

Trustworthiness assessment revealed the following concerns: two studies had a short time between last participant recruited to publication (≤6 months), in six additional studies this time could not be calculated. External validity was inconsistent between the studies, many excluding key demographics (ie. multiple pregnancies, rupture of membranes) or failing to report on important patient characteristics (ie. previous pre-term pregnancies, cervix status).

Conclusion: This systematic review of 24 RCTs assessing the efficacy of nifedipine tocolysis identified key areas of research design that must be addressed in future studies to produce pragmatic and useful data that appropriately inform clinical practice. Future studies should aim to address and report on prospective power calculations, patient centeredness initiatives, value for money calculations, and prospective trial registration as these were the criteria most lacking in the current sample set.

51: Peripartum maternal diaphragmatic hernia

Jessica Phillips¹, Sivanthi Senaratne¹

1. King Edward Memorial Hospital, Subiaco, Western Australia, Australia

Introduction: A diagnosis of maternal diaphragmatic hernia (MDH) in pregnancy and the post-partum period is uncommon but associated with poor maternal and fetal outcomes.

Case Presentation: A 21-year-old primigravida presented to a regional hospital at 40 weeks gestation with acute onset of nausea and vomiting in the setting of premature rupture of membranes. She subsequently developed dyspnoea, tachypnoea and left sided chest discomfort. A chest x-ray showed opacification of the left lower zone with an obscured costophrenic recess. She was started on antibiotics for suspected community acquired pneumonia and transferred to a tertiary centre.

Upon arrival, she underwent augmentation of labour and had a spontaneous vaginal delivery. During labour she became hypoxic and repeat chest x-ray post-partum showed the left lower zone opacity, now also containing an air fluid level consistent with an intrathoracic stomach. Computed tomography confirmed a defect in the central left hemidiaphragm, with herniation of the gastric body and a section of the transverse colon through the defect. There was collapse of the left lung and associated mediastinal shift.

She underwent endoscopic decompression and laparoscopic mesh repair of a 5 cm left sided diaphragmatic hernia and had an uneventful post-operative recovery. She was discharged with her baby after six days.

Discussion: Maternal diaphragmatic hernia (MDH) can be triggered by the anatomical changes of pregnancy or labour in the setting of an anomaly of the diaphragm.¹ The underlying diaphragmatic defect is usually pre-existing (post-traumatic, post-surgical or congenital) but often undiagnosed prior to pregnancy.

MDH is rare and presents with non-specific respiratory and gastrointestinal symptomology. These symptoms have significant overlap with more benign complaints of pregnancy, making MDH hard to diagnose.

In the contemporaneous literature (case reports from 2000 onwards); 28 of 46 cases of MDH had a documented alternative diagnosis, treatment plan or presented for medical review more than once before receiving a correct diagnosis.¹⁻⁴¹ The majority of these presented with typical symptoms: 79% with chest or epigastric pain, 50% with nausea and vomiting and 18% with dyspnoea.^{8, 15−41} Overall, MDH was associated with high maternal (9%) and fetal (15%) mortality. Preterm birth was also common, occurring in 46%.¹⁻⁴¹

Our case and literature review suggest that it is important to maintain an index of suspicion for MDH in women who present with any combination of chest or epigastric pain, dyspnoea or nausea and vomiting. Prompt diagnosis is essential to ensure maternal wellbeing and a successful pregnancy outcome.

52: Hydroxychloroquine as an effective steroid sparing agent in the treatment of secondary immune thrombocytopenia in pregnancy – 2 case reports

Juliana Yang^1,2, Briony Cutts^1,3

1. Department of Obstetric Medicine, Joan Kirner Women's and Children's at Sunshine Hospital, St Albans, VIC, Australia

2. Department of General Internal Medicine, Western Health, St Albans, VIC, Australia

3. Department of Obstetrics, Royal Women's Hospital, Parkville, VIC, Australia

Background: Immune thrombocytopenia (ITP) accounts for 3% of women who are thrombocytopenic at delivery, with up to 1% of these cases due to secondary ITP. No standardised therapy exists for moderate or severe systemic lupus erythematosus (SLE) associated thrombocytopenia and anti-phospholipid syndrome (APS) associated thrombocytopenia. Intravenous immunoglobulin (IVIg) and corticosteroids (CS) remain the first line treatment of primary ITP, however second line agents traditionally used in the non-pregnant population are potential teratogens. Hydroxychloroquine (HCQ) has been described with variable results as a potential second line agent.

Aim: We describe two case reports of significant secondary ITP with complete treatment response (CR) to HCQ. Case A - A 27-year-old primigravida with a platelet count of 58, following acute multifocal embolic strokes, related to a new diagnosis of triple antibody positive APS with ANA positivity. Case B - A 28-year-old, carrying monochorionic-diamniotic twins, with a photosensitive rash and platelet count of 2, related to a new diagnosis of SLE, with persistent lupus anticoagulant positivity.

Methods: We reviewed the treatment response during the index pregnancies of Case A and Case B, interrogating the platelet counts, disease activity markers, maternal and neonatal outcomes.

Results: Case A – HCQ was used as a first line agent, bypassing CS. CR was observed, with a platelet count of 141 following 4 weeks of treatment. She delivered by elective caesarean section (ELCS) with spinal anaesthesia at 38 weeks gestation, to a small for gestational age (SGA) neonate at 2290 g with an estimated blood loss (EBL) of 450 ml. There was no neonatal thrombocytopenia. She required suction curette at nine days post-partum for retained products of conception.

Case B – IVIG (2 mg/kg), prednisolone (50 mg daily) and a pool of platelets was administered acutely for a platelet count of 2 at 24 weeks gestation. On maintenance treatment of hydroxychloroquine 400 mg daily and prednisolone 25 mg daily, the platelet count was 108 at 8 weeks and 253 at 4 months of treatment, demonstrating complete and sustained treatment response. She delivered at 31 weeks gestation by ELCS with spinal anaesthesia, due to intermittent absent end diastolic flow (type 3 selective intrauterine growth restriction) in Twin B, with post-partum haemorrhage of 1.5 L. Twin A and Twin B had an uncomplicated course in neonatal intensive care for prematurity care. There was no neonatal thrombocytopenia.

Conclusion: These two cases highlight the potential role for HCQ in the management of secondary ITP as a second line option.

53: Socioeconomic factors that influence attendance to a postpartum cardiovascular disease prevention clinic for women with a history of pregnancy complications

lauran lh hinter ¹

1. Adelaide Medical School, University of Adelaide, Flinders Park, SA, Australia

Previous studies have outlined the importance of effective early post-partum interventions at reducing cardiovascular disease risk in women who have experienced a pregnancy complication. This led to the emergence of the COFFEE clinic, an early post-partum cardiovascular education and intervention service at the Lyell McEwin Hospital. The major problem facing the COFFEE clinic is only 50% of referred women attend their appointments. The aim of this retrospective study is to compare socioeconomic factors between women who attend their scheduled COFFEE clinic appointment and those who do not attend their appointment. This study analysed medical records of a preliminary sample of 696 women referred to the COFFEE clinic between the 1^st of January 2018 to the 31^st of December 2021. Differences in patient demographics and socioeconomic variables between women who attended and those who did not were completed using independent sample t-test, Fisher's exact test, chi-square tests and multivariate linear or logistic regressions. The preliminary results showed mean age of the cohort was 32 years, the majority were English speaking, and the majority were employed. Two-thirds of the cohort were referred for Gestational Diabetes Mellitus (69.1%) and one-third were referred for hypertensive disorders of pregnancy (34.3%). There were no statistically significant differences between women who attended and those who did not for any of the socioeconomic variable. The results of this study reveal a vulnerable group within this cohort of women who can be targeted for addition engagement.

54: A case of gestational diabetes insipidus

Weiying Lim ¹

1. Endocrinology, Singapore General Hospital, Singapore

A 35-year-old Chinese lady was on follow up for gestational diabetes mellitus (GDM) that was well controlled on metformin therapy. At around 32 weeks of gestation, she developed significant polyuria and polydipsia and reports having to drink and pee up to ten litres per day. She had cravings for cold, sugar-sweetened beverages. She denied headache, visual disturbance, and did not have symptoms suggestive of hypocortisolism and hypothyroidism.

Her biochemistry evaluation revealed serum sodium of 138 mmol/L, serum osmolality of 285 mmol/kg, and urine osmolality of 66 mmol/kg. Her liver function test was normal. Her thyroid function test showed fT4 of 8.0pmol/L, TT4 125 nmol/L, TSH 2.61 mu/L, which was appropriate for gestation.

She was started on nasal desmopressin at bedtime with improvement of symptoms. Her urine osmolality also increased to 669 mmol/kg. A magnetic resonance imaging (MRI) pituitary (non-contrast) which was performed prior to delivery showed normal sized pituitary gland with poorly visualised posterior pituitary bright spot, and central pituitary stalk. A provisional diagnosis of gestational diabetes insipidus was made.

She delivered via normal vaginal delivery uneventfully. She was reviewed at 2 and 5 weeks post-partum, but her symptoms were still persistent, suggesting the possibility of an alternative diagnosis, as most cases of gestational diabetes insipidus should resolve by 6 weeks post-partum.

At 3 months post-partum, her fT4 was low at 7.1pmol/l (Reference:8.8- 14.4), TSH 3.44 mu/L, serum sodium 140 mmol/L, serum osmolality 291 mmol/Kg, urine osmolality was 84 mmol/kg, and her 1 mcg Synacthen stimulation test showed appropriate peak cortisol response of 596 nmol/L. Repeat MRI pituitary scan (contrasted) showed that the pituitary gland appears prominent and showed prominent contrast enhancement. Normal high T1 signal intensity was noted in the posterior pituitary gland. There were no discrete nodules noted in the pituitary glands. As such, a diagnosis of hypophysiitis was considered.

In view of the risks associated with biopsy as the gold standard for determining the underlying aetiology, ancillary tests were performed instead. TB Quantiferon test, Syphyllis serology, Anti-nuclear antibody (ANA), Anti-neutrophil cytoplasmic antibody (ANCA), ENA screen were performed and returned unremarkable. She was started on levothyroxine 25 mcg om and continued on nasal ddAVP at bedtime.

Conclusion: True gestational diabetes insipidus, which usually develops in the thrid trimester and spontaneously remits 4–6 weeks post-partum due to excessive vasopressinase activity, is rare. Such patients should be followed up closely for an alternative diagnosis with careful follow-up of the other anterior pituitary hormone levels.

55: Cardiovascular investigations in pregnancy

Adam Morton¹, Lisa Shelley¹, Karam Kostner¹, Mugurel Nicolae¹

1. Mater Health, Brisbane

Cardiac disease represents the largest single cause of indirect maternal death, arrhythmias being the immediate or underlying cause in 10.7% of maternal cardiovascular deaths.^{1, 2} Physiological changes predispose to cardiovascular symptoms in pregnancy. Palpitations, dyspnoea, and syncope have been described in 11.5%, 37.5% and 1% of healthy pregnant women respectively. Holter monitoring in healthy asymptomatic pregnant women found supraventricular ectopic beats (SVEs) and ventricular ectopic beats (VEBs) in 58% and 52% of women. More than 100 SVEs per hour occurred in 4% of women, and more than 50 VEBs per hour occurred in 2% of women.³ A study of Holter monitoring in symptomatic pregnant women demonstrated that only 10% of symptomatic episodes were accompanied by arrhythmias.³ A retrospective review of the diagnostic yield of 24-h Holter monitoring, echocardiography, thyroid function and full blood count in previously healthy woman presenting with palpitations (66%), presyncope/syncope (32%), dyspnoea (23%) and chest tightness (8%) over a 3-year period was performed. 24-h Holter monitoring was performed on 183 women, mean age 30 years, mean BMI 27.6 kg/m². 24-h Holter monitoring revealed no significant arrhythmia in 141 women (77%), sinus tachycardia > 100bpm for > 10% recording in 26 women (14%), and significant arrhythmia in 16 women (8.7%) (13 > 1% VEBs, 2 with runs VT; 5 > 1% SVEs). Holter monitoring resulted in a change in therapy in 5 women (2.7%). Cardiovascular symptom type, maternal age, obesity, parity, or anaemia were not predictive of tachycardia or arrhythmia. Forty-five per cent of women recorded no symptomatic events during the 24-h recording. Ninety-two per cent of events recorded correlated with sinus rhythm, sinus tachycardia or sinus rhythm with isolated VEBs. Echocardiography revealed abnormalities in 2 women (1.8%), 1 woman with mitral valve prolapse, and another woman with dilated cardiomyopathy in setting 32% ventricular ectopic beats. Thyroid function was normal in 122/122 patients, 12/183 (6.6%) had Hb < 105 g/dL. No adverse clinical cardiac events occurred during pregnancy. 24-h Holter monitoring, and echocardiography have a relatively low diagnostic yield in investigating women without underlying cardiovascular disease who develop cardiovascular symptoms in pregnancy. Further studies examining monitoring with longer periods with Holter monitoring, 14-day adhesive patch electrocardiographic monitoring, event loop recording, Smart Watch devices or the Kardiamobile smartphone monitor increases detection of arrhythmias resulting in change in management and outcome in this low-risk population may be worthwhile.

Most women can be reassured that their symptoms are likely to be benign.

1. Knight M, Bunch K, Kenyon S, et al. A national population-based cohort study to investigate inequalities in maternal mortality in the United Kingdom, 2009–17. Paediatr Perinat Epidemiol 2020; 34: 392–398. 2020/02/06. DOI: 10.1111/ppe.12640.

2. Briller J, Koch AR, Geller SE, et al. Maternal Cardiovascular Mortality in Illinois, 2002–2011. Obstet Gynecol 2017; 129: 819–826. 2017/04/07. DOI: 10.1097/AOG.0000000000001981.

3. Shotan A, Ostrzega E, Mehra A, et al. Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope. Am J Cardiol 1997; 79: 1061–1064. 1997/04/15. DOI: 10.1016/s0002-9149(97)00047-7.

56: Gordon's syndrome in pregnancy

Adam Morton ¹

1. Mater Health, Brisbane

Gordon's syndrome, also known as pseudohypoaldosteronsim type II and familial hyperkalaemic hypertension, is a rare inherited condition characterised by familial hyperkalaemia, normal anion gap hyperchloraemic metabolic acidosis and low renin with normal glomerular filtration rate. Variable features include hypertension, hypercalciuria, short stature, low aldosterone, and dental anomalies. Gordon syndrome is caused by gain of function mutations in the genes regulating the thiazide-sensitive sodium-chloride transporter channel located on the distal convoluted tubules of renal nephrons.¹ Four genes have been implicated - WNK1 on chromosome 12, WNK4 on chromosome 17, CUL3 on chromosome 2 and KLHL3 on chromosome 5.² Gordon syndrome is usually inherited as an autosomal dominant condition with high penetrance although autosomal recessive inheritance has been described with KLHL3, and de novo mutations have been reported.³

Individuals with a CUL3 variant have more severe hyperkalaemia and metabolic acidosis, earlier and more severe hypertension, and greater likelihood of growth impairment compared to those harbouring KLHL3, WNK1, or WNK4 alterations.⁴

Thirteen pregnancies in 7 women with Gordon's syndrome have been described previously. A further 11 pregnancies in 3 women with Gordon's syndrome have been combined and the outcomes reviewed.

Eleven pregnancies occurred in 5 women who had hypertension preconception. Pregnancy complications were eclampsia and fetal death in one pregnancy, preeclampsia (4 cases), fetal growth restriction (FGR) (3), hypertension at term (3), and delivery prior to 37 weeks gestation in 4 pregnancies.

Thirteen pregnancies occurred in 5 women with normal blood pressure pre-conception. These pregnancies were complicated by preeclampsia (1 case), FGR (1), placental abruption (1), delivery prior to 37 weeks (3), fetal symbrachydactyly (1)l, fetal echogenic bowel and short long bones. (1)

Eleven pregnancies were to women taking thiazide diuretics pre-conception. Thiazides were continued during 6 pregnancies. These 6 pregnancies were complicated by PET (4 cases) and FGR (4). No congenital anomalies occurred.

Maternal serum potassium varied but did not provide management issues.

The results for genetic testing were available for only 4 women. One woman had WNK4 and another KLHL3 mutation. Two sisters tested negative for WNK1 and WNK4 – KLHL3 and CUL3 testing were not performed. Pregnancies in these 4 women were uncomplicated other than one case of PPROM and three cases of hypertension at term.

Gordon's syndrome appears to be associated with a high risk of pregnancy complications, especially in women with preconception hypertension. Assessing whether specific mutations predict adverse pregnancy outcomes would be valuable.

1. Proctor G and Linas S. Type 2 pseudohypoaldosteronism: new insights into renal potassium, sodium, and chloride handling. Am J Kidney Dis 2006; 48: 674–693. 2006/09/26. DOI: 10.1053/j.ajkd.2006.06.014.

2. Glover M, Ware JS, Henry A, et al. Detection of mutations in KLHL3 and CUL3 in families with FHHt (familial hyperkalaemic hypertension or Gordon's syndrome). Clin Sci (Lond) 2014; 126: 721–726. 2013/11/26. DOI: 10.1042/CS20130326.

3. O'Shaughnessy KM. Gordon Syndrome: a continuing story. Pediatr Nephrol 2015; 30: 1903–1908. 2014/12/17. DOI: 10.1007/s00467-014-2956-7.

4. Boyden LM, Choi M, Choate KA, et al. Mutations in kelch-like 3 and cullin 3 cause hypertension and electrolyte abnormalities. Nature 2012; 482: 98–102. 2012/01/24. DOI: 10.1038/nature10814.

57: Akathisia and oculogyric crisis in hyperemesis gravidarum

Adam Morton¹, Julian Pavey¹

1. Mater Health, Brisbane

Hyperemesis gravidarum (HG) complicates 0.5–2% of pregnancies. Anti-emetic therapy (AET) may cause extrapyramidal side-effects (EPS). Cognitive dysfunction, hallucinations and severe agitation with akathisia may lead to self-harm.¹ Akathisia may be overlooked or incorrectly attributed to a primary mental health disorder, hysteria, or a functional disorder. A case of akathisia and oculogyric crisis due to AET for HG is presented. The treatment options for EPS and ongoing treatment of HG are discussed.

A 20-year primigravid presented at 8 weeks’ gestation with a 3-week history of HG despite taking ondansetron, metoclopramide, pyridoxine-doxylamine, and omeprazole. Intravenous fluids were commenced, and 2 doses of intravenous prochlorperazine administered in addition to existing medications. The woman subsequently complained of extreme agitation, restlessness, and anxiety. She manifested a hyperextended neck and fixed conjugate upward gaze consistent with akathisia and oculogyric crisis. Prochlorperazine, metoclopramide and ondansetron treatment were ceased, and antihistamines, intravenous hydrocortisone and thiamine were administered. The EPS and vomiting resolved overnight.

One case of oculogyric crisis and two cases of acute dystonia have been reported following prochlorperazine therapy for HG.²³⁴

Oculogyric crises have been described following metoclopramide and ondansetron therapy in non-pregnant individuals.^{5, 6} Akathisia has been reported in 9–44%, 5–32% and 0.8–3% of non-pregnant individuals treated with prochlorperazine, metoclopramide and ondansetron respectively.^{7, 8}

Cytochrome P450 2D6 genetic polymorphisms may predispose to acute dystonic reactions with metoclopramide, prochlorperazine and ondansetron due to slowing of drug metabolism.⁹

EPS usually resolve within 24–48 h of drug cessation. Anticholinergic and antihistamine medications may be used for severe symptoms. Intravenous diphenhydramine is the drug of choice in pregnancy. Ondansetron may not be reversed by diphenhydramine, and short-term benzodiazepines may be preferable.¹⁰

Drug-induced EPS affects the management of HG. Akathisia and dystonia have been reported following the use of mirtazapine, promethazine, cyclizine, droperidol and gabapentin. Doxylamine, diphenhydramine and glucocorticoids may be used safely. EPS has not been described with granisetron . Benzodiazepines may be therapeutic in HG and EPS though with a potential risk of prematurity and low birth weight. Transdermal scopolamine and clonidine may be effective in the management of HG and EPS.

Oculogyric crises are rare though easily recognised. The incidence of akathisia is unknown, and it may be overlooked. Obstetric physician's awareness of the potential for akathisia with anti-emetic s for HG is important.^{1, 11}

1. Cheng HM, Park JH and Hernstadt D. Akathisia: a life-threatening side effect of a common medication. BMJ Case Rep 2013; 2013 2013/05/24. DOI: 10.1136/bcr-2012–007713.

2. Williams P AH. Akathisia preceding an oculogyric crisis in a patient treated with prochlorperazine for hyperemesis gravidarum. Case Rep Perinat Med 2014; 3: 15–17.

3. Beirne M and Fenton J. Acute dystonic reaction secondary to prochlorperazine use in the treatment of hyperemesis gravidarum. Ir J Med Sci 2007; 176: 53–54. 2007/09/13. DOI: 10.1007/s11845–007-0005-2.

4. Coralic Z, Kim AS and Vinson DR. Prochlorperazine-Induced Hemidystonia Mimicking Acute Stroke. West J Emerg Med 2015; 16: 572–574. 2015/08/13. DOI: 10.5811/westjem.2015.4.26003.

5. Macachor JD, Kurniawan M and Loganathan SB. Ondansetron-induced oculogyric crisis. Eur J Anaesthesiol 2014; 31: 712–713. 2014/10/12. DOI: 10.1097/EJA.0000000000000169.

6. Koban Y, Ekinci M, Cagatay HH, et al. Oculogyric crisis in a patient taking metoclopramide. Clin Ophthalmol 2014; 8: 567–569. 2014/03/29. DOI: 10.2147/OPTH.S60041.

7. Patka J, Wu DT, Abraham P, et al. Randomized Controlled Trial of Ondansetron vs. Prochlorperazine in Adults in the Emergency Department. West J Emerg Med 2011; 12: 1–5. 2011/06/22.

8. Miller LG and Jankovic J. Metoclopramide-induced movement disorders. Clinical findings with a review of the literature. Arch Intern Med 1989; 149: 2486–2492. 1989/11/01. DOI: 10.1001/archinte.149.11.2486.

9. Wong DY and Fogel BL. Acute pharmacogenetic dystonic reactions in a family with the CYP2D6 *41 allele: a case report. J Med Case Rep 2021; 15: 432. 2021/08/20. DOI: 10.1186/s13256-021-03022-x.

10. Spiegel JE, Kang V, Kunze L, et al. Ondansetron-induced extrapyramidal symptoms during cesarean section. Int J Obstet Anesth 2005; 14: 368–369. 2005/09/13. DOI: 10.1016/j.ijoa.2005.06.001.

11. Wright MT. Antiemetics, akathisia, and pregnancy. Psychosomatics 2007; 48: 461–466. 2007/12/12. DOI: 10.1176/appi.psy.48.6.461.

58: A late postpartum seizure

Adam Morton ¹

1. Mater Health, Brisbane

Postpartum seizures have a broad differential diagnosis. Common causes include eclampsia, cerebral vein sinus thrombosis (CVST), posterior reversible encephalopathy (PRES), cerebral haemorrhage, drug withdrawal and metabolic abnormalities. Correct diagnosis is crucial to acute management and the risk of recurrence in subsequent pregnancy.

A 22-year-old primigravida with no significant history was induced post-dates with epidural anaesthesia. Sixteen hours after rupture of membranes emergency caesarean section was performed for obstructed labour and abnormal cardiotocogram. A live female birthweight 5270 g was delivered. The woman re-presented 5 days postpartum because of hypogastric pain. Upon sitting up abruptly following a pelvic ultrasound she manifested 2 episodes of tonic-clonic convulsions each lasting 5–10 min followed by post-ictal confusion. Physical examination revealed temperature 36.8^o, BP 130/80 mmHg, no proteinuria, no neck stiffness, mild hyperreflexia but no clonus. The woman was treated with intravenous midazolam and magnesium sulphate infusion, acyclovir, and ceftriaxone. Biochemistry and haematology tests were normal, magnetic resonance (MRI) venography showed diffuse pachymeningeal enhancement with distended dural venous sinuses consistent with intracranial hypotension. Electroencephalogram was unremarkable. The woman complained of 6/10 headache, tinnitus, and shoulder stiffness. She declined an epidural blood patch.

MRI in 136 women with postpartum convulsions revealed no abnormality in 36%, CVST in 24%, PRES in 21%, intracerebral haemorrhage in 7% and subarachnoid haemorrhage in 4%.^{1, 2}

Unintentional dural puncture complicates 0.6–2.7% of labour epidural catheter placement, with this being unrecognised at time of anaesthesia in 16–38% of cases.³ Eighteen previous cases of seizures following epidural anaesthesia in pregnancy in the setting of headache and radiological signs of intracranial hypotension and in the absence of an alternative cause have been reported. Seizures occurred between 2–7 days postpartum Dural puncture and intracranial hypotension may also be complicated by subdural, subarachnoid, and cerebral haemorrhage, CVST, PRES, Horner's syndrome, cranial nerve palsies, auditory loss, and infection. Post-dural puncture headache with intracranial hypotension may be atypical without a positional component in 5.6% of cases.⁴

Seizures and other neurological complications postpartum result in significant maternal (and physician) anxiety particularly when unexplained. Awareness of the broad range of potential complications with intracranial hypotension following dural puncture is important for reassuring women developing these complications both immediately and with regard to future pregnancy.

1. El Ameen N AM, Kotb A. MRI of the brain in postpartum convulsions; pose diagnostic dilemnas. The Egyptian Journal of Radiology and Nuclear Medicine 2017; 48: 999–1004.

2. Hiremath R, Mundaganur P, Sonwalkar P, et al. Cross sectional imaging of post partum headache and seizures. J Clin Diagn Res 2014; 8: RC01-05. 2015/02/06. DOI: 10.7860/JCDR/2014/8783.5234.

3. Richardson MG, Lee AC and Wissler RN. High spinal anesthesia after epidural test dose administration in five obstetric patients. Reg Anesth 1996; 21: 119–123. 1996/03/01.

4. Loures V, Savoldelli G, Kern K, et al. Atypical headache following dural puncture in obstetrics. Int J Obstet Anesth 2014; 23: 246–252. 2014/06/18. DOI: 10.1016/j.ijoa.2014.04.005.

59: Comparison of women presenting with hypertensive disorders of pregnancy antenatally versus de-novo postpartum hypertension

Nadia Olivier^1,2, Helen McDougall^1,3, Grace Yuan⁴, Mark Tacey⁵, David Langsford^1,4,6

1. Medical Obstetrics, Northern Health, Melbourne, Victoria, Australia

2. Obstetrics and Gynaecology Resident, Northern Health, Melbourne, Victoria, Australia

3. Advanced Trainee in General Medicine, Northern Health, Melbourne, Victoria, Australia

4. Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia

5. Biostatistics, Northern Health, Melbourne, Victoria, Australia

6. Head of Medical Obstetrics and Nephrologist, Northern Health, Melbourne, Victoria, Australia

Background: Hypertension is a leading cause of postpartum readmissions (1), with de novo postpartum hypertension accounting for the large majority of readmissions (2). Identifying associations may aid in the recognition of those at risk and assist to prevent these readmissions.

Aim: To describe the characteristics of patients presenting with postpartum hypertension. To compare those with known hypertensive disorders of pregnancy (HDP) to those who represent with postpartum hypertension de novo (dnHDP).

Methods: A retrospective cross-sectional audit was conducted of the deliveries at Northern Health from 1^st January 2016 to 31^st December 2020. Data was collected through the birthing outcomes system, discharge summary ICD 10 codes and a manual search of a sample of representative medical records. Demographics, birth outcomes, antenatal care, comorbidities, pathology, blood pressure readings and re-presentation aetiology were recorded.

Tests for statistical significance (Chi-square, Mann-Whitney) were conducted when relevant.

Results: Seventy-two patients had an admission for post-partum hypertension, 35 (48.6%) readmissions had HDP and 37 (51.4%) had dnHDP.

A number of similarities were observed between the patients with HDP and the dnHDP group, including socioeconomic status, maternal age at delivery (32.4 ± 4.9, 31.9 ± 5.6 years), BMI (32 (25–38), 31 (24–41) kg/m²) nulliparity (48.6%, 40.5%) and antenatal aspirin prescription (28.6%, 27%).

The median birthweight of the HDP group was less (3130 (2790–3410) grams) compared to the dnHDP (3290 (3020–3800) grams). There was less gestational diabetes mellitus (GDM) in the HDP versus group (20% versus 40.5%) (p = 0.08).

Differences were observed in the urine protein to creatinine ratio (uPCR) antenatally. The HDP group had 48.6% with a uPCR >30 mg/mmol compared to 2.7% in the dnHDP group within 4 weeks of delivery (p < 0.001).

Antenatally, the median blood pressure readings for the HDP were higher than the dnHDP group, who had normal antenatal blood pressure readings. Postpartum, the median blood pressure readings were elevated in both groups (174/107 mmHg – HDP, 160/100 mmHg – dnHDP), however the HDP were significantly more elevated (SBP p = 0.031, DBP <0.001).

Conclusions: Antenatally, HDP and dnHDP patients are similar, although some important differences were identified: antenatal blood pressure, proteinuria and GDM. Our study is limited by being retrospective and having a small sample size. No risk factors for dnHDP beyond those associated with HDP were identified. However, as it does not appear that dnHDP can be accounted for as being unrecognised HDP this may raise questions as to the aetiology of dnHDP and further investigation in this area may be warranted.

1. De Zoysa M, Chung JH, Adkins K, Steller J. Factors associated with postpartum readmission for hypertensive disorders of pregnancy. American Journal of Obstetrics & Gynecology. 2022;226(1):S462-S3.

2. Al-Safi Z, Imudia AN, Filetti LC, Hobson DT, Bahado-Singh RO, Awonuga AO. Delayed Postpartum Preeclampsia and Eclampsia: Demographics, Clinical Course, and Complications. Obstetrics & Gynecology. 2011;118(5).

60: Panhypopituitarism in pregnancy: a case study and literature review

Dianna Luong^1,2, Stephanie Teasdale²

1. School of Medicine, University of Queensland, Brisbane, Queensland, Australia

2. Queensland Diabetes and Endocrine Centre, Mater Hospital Brisbane, Brisbane, QLD, Australia

JM, a 34-year-old woman, G3P1, presented with hypertension at 32 weeks’ gestation. She had Type 1 Diabetes Mellitus and was experiencing hypoglycaemic episodes despite reducing her insulin. TFTs revealed a TSH of 2.55 mIU/L and T4 of <5.2pmol/L whilst on Thyroxine 75micrograms daily for Hashimoto's thyroiditis.

She naturally conceived in 2015, however could not breastfeed and experienced long-term fatigue post-delivery. She had a miscarriage in 2020 following ovarian induction with clomiphene for presumed polycystic ovarian syndrome. Her current pregnancy was via IVF.

An anterior pituitary hormone panel revealed secondary adrenal insufficiency (Table 1). A non-contrast MRI pituitary showed only a partial empty sella with no pituitary lesion (Figure 1). Retrospectively, a low TSH was present 3-months post-delivery of her first child (Figure 2). Whilst the aetiology of her panhypopituitarism remained unclear, it was thought likely to have occurred between her first two pregnancies.

Hydrocortisone replacement was commenced (12miligrams mane, 8miligrams midi), and her Thyroxine was increased to 150micrograms daily with symptomatic improvement. Her hypoglycaemic events resolved. She underwent a caesarean section with hydrocortisone stress dosing at 36 weeks’ gestation for foetal indications.

Now 6 weeks post-partum, JM has had one menstrual cycle. She is euthyroid (TSH 0.6 mIU/L [0.3–3.5 mIU/L], T4 12.6pmol/L [9.0–19.0pmol/L]) on Thyroxine 150micrograms daily. A repeat anterior pituitary screen remains concerning for panhypopituitarism –IGF-1 6 nmol/L (11–38 nmol/L), Prolactin 163 mIU/L (<500 mIU/L), FSH 8IU/L, LH 3IU/L, Oestradiol 148pmol/L. An overnight Metyrapone test suggests persistent central adrenal insufficiency with an ACTH 28 ng/L (9–51 ng/L), cortisol <50 nmol/L (100–535 nmol/L) and a 11-deoxycortisol of 104.4 nmol/L (>200 nmol/L).

Panhypopituitarism is rare and associated with miscarriage, gestational hypertension, placental abruption, and post-partum haemorrhage.¹ Pregnancy-related conditions resulting in panhypopituitarism include Sheehan's syndrome and lymphocytic hypophysitis.² Non-pregnancy conditions include lesions with mass effect on the pituitary and/or stalk, Empty Sella syndrome, infiltrative disease, head injury and iatrogenicity (Table 2).³

Symptoms are often non-specific and dependent on the degree of hormones affected. An intact hypothalamic-gonadal-axis is required to achieve a successful pregnancy and the diagnosis is often made when investigating infertility.⁴ Failure of lactation postpartum holds high specificity.⁵

Furthermore, prolactin, cortisol and thyroid levels have trimester-specific cut offs, and dynamic testing should be cautiously interpreted due unclear reference ranges. IGF-1 levels are affected by oestrogen, and current assays cannot distinguish placental from maternal growth hormone.⁶ MRI has limited value given the inability to use gadolinium contrast during pregnancy. Therefore, a high clinical suspicion is often required when investigating pregnant women for hypopituitarism.

1. Du X, Yuan Q, Yao Y, Li Z, Zhang H. Hypopituitarism and successful pregnancy. Int J Clin Exp Med. 2014 Dec 15;7(12):4660–5. PMID: 25663963; PMCID: PMC4307410.

2. Karaca Z, Tanriverdi F, Unluhizarci K, Kelestimur F. Pregnancy and pituitary disorders. Eur J Endocrinol. 2010 Mar;162(3):453–75. doi: 10.1530/EJE-09-0923. Epub 2009 Nov 24. Erratum in: Eur J Endocrinol. 2010 Jun;162(6):1167. PMID: 19934270.

3. Kim SY. Diagnosis and Treatment of Hypopituitarism. Endocrinol Metab (Seoul). 2015 Dec;30(4):443–55. doi: 10.3803/EnM.2015.30.4.443. PMID: 26790380; PMCID: PMC4722397.

4. Vila G, Fleseriu M. Fertility and Pregnancy in Women With Hypopituitarism: A Systematic Literature Review. J Clin Endocrinol Metab. 2020 Mar 1;105(3):dgz112. doi: 10.1210/clinem/dgz112. PMID: 31652320

5. Bhushan D, Agarwal M, Shukla RK. Hypopituitarism: A Rare but Often Neglected Condition. Indian J Crit Care Med. 2020 May;24(5):350–352. doi: 10.5005/jp-journals-10071–23422. PMID: 32728328; PMCID: PMC7358872.

6. Morton A, Teasdale S. Physiological changes in pregnancy and their influence on the endocrine investigation. Clin Endocrinol (Oxf). 2022 Jan;96(1):3–11. doi: 10.1111/cen.14624. Epub 2021 Nov 1. PMID: 34724247.

7. Abbassi-Ghanavati M, Greer LG, Cunningham FG. Pregnancy and laboratory studies: a reference table for clinicians. Obstet Gynecol. 2009 Dec;114(6):1326–1331. doi: 10.1097/AOG.0b013e3181c2bde8. Erratum in: Obstet Gynecol. 2010 Feb;115(2 Pt 1):387. PMID: 19935037.

61: Dietary carbohydrate intake is not correlated with circulating beta-hydroxybutyrate levels in overweight and obese pregnant women at 28 weeks gestation

Helen Tanner¹, Hui Ting Ng², Grace Murphy², Helen Barrett^3,4, Leonie Callaway¹, David McIntyre³, Marloes Dekker Nitert²

1. The Royal Brisbane and Women's Hospital, Herston, QLD, Australia

2. School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane, Queensland, Australia

3. Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia

4. Royal Hospital for Women, Randwick, NSW

Background: The second half of pregnancy has been termed a state of accelerated starvation, with increased production of ketone bodies including beta-hydroxybutyrate (B-OHB) from stored lipids. Normal B-OHB levels are considered to be less than 0.5 mmol/L. Maternal serum ketone levels ranging from 0.05–0.25 mmol/L have been found to be inversely associated with childhood IQ. However studies have found conflicting results. Current dietary guidelines advise pregnant women to consume 175 g of carbohydrates daily to prevent ketogenesis. The aim of this study was to analyse the relationship between dietary carbohydrate intake and circulating B-OHB levels at 28 weeks gestation.

Methods: B-OHB levels were measured by Liquid Chromatography-Mass Spectrometry in fasting blood samples of 107 overweight and obese participants in the SPRING (Study of PRobiotics IN Gestational diabetes) trial with carbohydrate intakes between 73 and 374 g/d as assessed by food frequency questionnaire at 28 weeks gestation. Differences in B-OHB levels were evaluated by Mann-Whitney U tests given that the data was not normally distributed. B-OHB levels were correlated with carbohydrate and other macronutrient intake, biochemical markers, OGTT levels and clinical characteristics.

Results: The median circulating B-OHB level was 0.062 mmol/L (IQR 0.038–0.098, range 0.0001–0.297 mmol/L) . Circulating B-OHB levels did not correlate with carbohydrate intake (Spearman's rho = 0.14, P = 0.16) nor intake of any other macronutrient, maternal BMI, age, gestational weight gain, infant birthweight or infant length. The 1-h OGTT blood glucose level was the only biochemical marker that was marginally correlated with B-OHB levels (rho 0.19, P = 0.056). When comparing women with B-OHB levels below and above the median of 0.062 mmol/L, the only marginal difference was in 1-h OGTT blood glucose level (below median B-OHB: 6.7 mM vs. above median B-OHB: 7.3 mM, P = 0.085).

Conclusion: Detectable circulating B-OHB levels were present in all participants and within the range associated with reduced childhood IQ. Carbohydrate intake at 28 weeks gestation does not affect circulating B-OHB levels in overweight and obese pregnant women. The higher 1-h OGTT glucose values in women with higher fasting B-OHB concentrations could reflect a lower carbohydrate intake in the 24 h before the OGTT, which was not recorded in this study. In summary, low levels of circulating B-OHB are common in late pregnancy and are not associated with routine dietary macronutrient intake.

62: Alagille syndrome complicated by early onset preeclampsia

Julian Pavey^1,2, Adam Morton^1,2, Caroline Wilson^1,2

1. Mater Hospital, South Brisbane, QLD, Australia

2. University of Queensland, Brisbane

Alagille syndrome (ALGS) is a complex multisystem condition caused by mutations in JAG1 or NOTCH2genes.(1) The incidence is estimated to be 1:35000 individuals.(2) The mutation occurs de novo in 60% of affected individuals, the remainder being autosomal dominant.(3) Characteristic features include bile duct paucity, cholestasis, cardiac malformations, ocular disorders, renal anomalies, renovascular disease and cerebrovascular abnormalities, hypertension, abnormal facies and short stature.(2) ALGS may manifest significant intrafamilial variability in manifestations.(4)

A 38-year-old primigravid was admitted at 21 weeks’ gestation with new hypertension and headache. ALGS was diagnosed in childhood after her sister presented with cholestasis, ultimately requiring liver transplantation. Her father and paternal cousin were also affected. Manifestations of ALGS included typical facies, mild-moderate pulmonary stenosis (peak/mean gradient 36/17 mmHg) and pigmentary retinopathy. At 8 weeks’ gestation serum creatinine had been 79umol/L (normal < 78), urine protein:creatinine and liver function tests normal. On examination, blood pressure was 169/73 mmHg with bilateral ankle oedema. Urine protein-creatinine ratio was now elevated at 46 mg/mmol (normal <30). There were no other clinical or biochemical features of pre-eclampsia. Labetalol was commenced with good effect. Autoimmune, vasculitis and antiphospholipid screens were negative. Phaeochromocytoma, primary aldosteronism, renal artery stenosis and hyperthyroidism were excluded.

The woman's blood pressure was well controlled on twice-weekly outpatient visits until she re-presented at 26 weeks’ gestation with hypertension and a severe retroorbital headache. Urine protein-creatinine ratio had increased to 178 mg/mmol. Satisfactory growth and normal dopplers was seen on fetal ultrasound. CT head venogram excluded dural venous sinus thrombosis and intracranial haemorrhage. Antihypertensives were uptitrated initially with good effect. She developed episodes of severe hypertension over the subsequent 48 h requiring oral nifedipine and intravenous hydralazine. Delivery was indicated given her severe hypertension in the setting of pre-eclampsia. She underwent emergency classical caesarean section and delivered an 878 gram boy at 26 weeks and 3 days gestation.

Including this case, 12 successful pregnancies have been described in women with ALGS.(5) Complications included fetal growth restriction (FGR-7cases), pre-eclampsia (2), maternal cholestasis (2), HELLP syndrome (1) and postpartum maternal pulmonary oedema (1).(5) Miscarriage rates of 27% have been reported after 10 weeks’ gestation.(4) ALGS represent high risk pregnancies. Specific management considerations include assessment of the severity of cardiac disease, monitoring for liver dysfunction, cholestasis, renal dysfunction and pre-eclampsia as well as monitoring for FGR.(5) DNA-based pre-implantation and prenatal diagnosis of ALGS may be performed.(6)

1. Mitchell E, Gilbert M, Loomes KM. Alagille Syndrome. Clin Liver Dis. 2018;22(4):625–41.

2. Kamath BM, Baker A, Houwen R, Todorova L, Kerkar N. Systematic Review: The Epidemiology, Natural History, and Burden of Alagille Syndrome. J Pediatr Gastroenterol Nutr. 2018;67(2):148–56.

3. Hannoush ZC, Puerta H, Bauer MS, Goldberg RB. New JAG1 Mutation Causing Alagille Syndrome Presenting With Severe Hypercholesterolemia: Case Report With Emphasis on Genetics and Lipid Abnormalities. J Clin Endocrinol Metab. 2017;102(2):350–3.

4. Elmslie FV, Vivian AJ, Gardiner H, Hall C, Mowat AP, Winter RM. Alagille syndrome: family studies. J Med Genet. 1995;32(4):264–8.

5. Morton A, Kumar S. Alagille syndrome and pregnancy. Obstet Med. 2021;14(1):39–41.

6. Renbaum P, Brooks B, Kaplan Y, Eldar-Geva T, Margalioth EJ, Levy-Lahad E, et al. Advantages of multiple markers and polar body analysis in preimplantation genetic diagnosis for Alagille disease. Prenat Diagn. 2007;27(4):317–21.

63: Current situation of bile acid measurements throughout Australia

Corey Markus¹, Suzette Coat², Hanns-Ulrich Marschall³, Susan Matthews¹, Wayne Rankin^4,5,6, Bill Hague²

1. Flinders University International Centre for Point-of-Care Testing, Adelaide, Australia

2. Robinson Research Institute, The University of Adelaide, Adelaide, Australia

3. University of Gothenburg, Gothenburg, Sweden

4. Chemical Pathology Directorate, SA Pathology, Adelaide, South Australia

5. Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA

6. Adelaide Medical School, The University of Adelaide, Adelaide, SA

Assay standardisation is an underappreciated aspect in the setting of large-scale international clinical trials, particularly those combining patient results from different laboratory services. Assay standardisation has been gaining increasing attention, especially for frequently ordered analytes, e.g., Creatinine and HbA1c, which have clearly defined medical decision points derived from strong outcome studies. In the case of bile acid (BA) measurements, this situation is less certain and results from quality assurance programs demonstrate significant methodological variations. Furthermore, these methodical variations may be reflected in results for patient samples.

In recognition of the between-laboratory heterogeneity in BA results, the Bile Acid Comparison and Harmonisation (BACH) study was established as a sub-study of the international randomised ‘Trial of URsodeoxycholic acid vs. RIFampicin in severe early-onset Intrahepatic Cholestasis of pregnancy’ (TURRIFIC). We here show results from the BACH project with respect to methodology questionnaires, between-laboratory variability in results and the potential for mathematical recalibration and harmonisation for Australian laboratories servicing TURRIFIC recruitment sites.

Laboratories providing BA measurements for TURRIFIC in Australia were invited to participate in the BACH project, with participation considered as an in-kind contribution. Pooled serum comparison samples were prepared from remainder clinical samples and, to obtain pools with higher BA values, some were spiked with bile or discrete BA species. Commutability — the relationship of spiked serum samples with native clinical samples — was assessed in a manner consistent with international guidelines. Mathematical recalibration and harmonisation were investigated via a consensus value approach using the median value of each sample from all participating laboratories.

Nine laboratories were recruited into BACH, all of which responded to the methodological questionnaire, and all assayed the full comparison sample set. Participants represented the commonly used commercial enzymatic reagents: four sites using Randox, three Diazyme and two Abbott reagents. One reagent manufacturer displayed minor assay non-linearity. Sixty pooled serum comparison samples were produced, including eleven spiked with bile fluid or BA species. Glycodeoxycholic and cholic acids demonstrated potential commutability as reference materials. Recalibration and harmonisation decreased the between-laboratory variability from 8.8% to 2.5% pre- and post-harmonisation respectively: a reduction of 72%.

We have presented an overview of the current situation for BA measurements in Australia and successfully demonstrated harmonisation of BA results, allowing pooling of results for statistical analysis. We aim to extend this study to the European sites, using the same reference samples and including mass spectrometry reference methods.

64: Prescription retinoid and concomitant contraception use in reproductive aged women in Australia

Laura Gerhardy¹, Natasha Nassar², Melisa Litchfield³, Debra Kennedy¹, Annika Smith^5,4, Malcolm Gillies³, Sallie Pearson³, Helga Zoega^3,6,7, Antonia Shand^2,1,6

1. Royal Hospital for Women, Randwick, NSW, Australia

2. Child population and Translational Health Research, Children's Hospital at Westmead Clinical School and Menzies Centre for Health Policy and Economics, University of Sydney, Camperdown, NSW, Australia

3. School of Population Health, University of New South Wales, Kensington, NSW, Australia

4. University of New South Wales, Darlinghurst, NSW, Australia

5. St Vincent's Hospital, Darlinghurst, NSW, Australia

6. co-last authors,

7. Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Iceland

Background: Retinoids are medicines used to treat severe cystic acne and other dermatological conditions, and to counteract the effects of photoaging. Retinoids can be used orally or topically. Oral retinoids are teratogenic if taken in pregnancy. Contraception is therefore recommended in reproductive-aged women taking oral retinoids.

Objectives: To determine the demographic characteristics and trends in use of prescription retinoids among reproductive-aged women in Australia, and to determine whether women dispensed retinoids are concomitantly dispensed contraception.

Methods: We used Pharmaceutical Benefits Scheme (PBS) dispensing claims from a 10% random sample of Australian reproductive-aged women (15–44 years) between 2013 to 2021. We described annual numbers and trends in dispensing of PBS-listed retinoids and PBS-listed contraceptives, and determined prevalence of use using ABS age-sex specific population estimates as denominators. Each retinoid dispensing was analysed for whether there was a concomitant contraceptive dispensing within an appropriate time frame to reasonably assume contraception co-use. We multiplied results by 10 to extrapolate to population numbers.

Results: During the study period, we observed 1,545,800 retinoid dispensings and 21,943,370 contraceptive dispensings. The number of reproductive-aged women with a retinoid dispensing increased from 61,080 in 2013 to 92,590 in 2021 (an increase in prevalence of use from 1.3% to 1.8%). The prevalence of oral retinoid use doubled over the study period, while topical retinoid prevalence of use remained static. Oral retinoid dispensings were highest among younger women, and decreased with increasing age. Contraceptive dispensings reduced across the study period, but this was driven largely by a decrease in combined oral contraceptive dispensings (with 4 months duration of contraception coverage), and an increase in levonorgestrel intrauterine device dispensings (with 5 years duration of contraception coverage). When accounting for the contraceptive time supplied with a dispensing, contraceptive coverage remained stable across the study period. Amongst women receiving an oral retinoid dispensing, only 25% had a contraception concomitant dispensing in 2021, rising from 19% in 2013.

Conclusions: Oral retinoid use in Australian reproductive-aged women has increased between 2013 and 2021, while PBS contraception coverage has remained static. A large proportion of women dispensed oral retinoids were not concomitantly dispensed PBS contraception, posing a risk of unplanned pregnancy and congenital anomaly. However, it should be noted that approximately 20% of hormonal contraceptive use in Australian women aged 18–39 is not listed on the PBS, and thus not captured in this study.¹ Initiatives are required to improve contraception use in women dispensed oral retinoids.

1. Skiba MA, Islam RM, Bell RJ, Davis SR. Hormonal contraceptive use in Australian women: Who is using what?. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2019 Oct;59(5):717–24.

65: A case of postpartum splenic infarction

Ko-Chia Jasmine Lin¹, Vishwas Raghunath¹, Michelle Cole¹

1. Division of Medicine, Ipswich Hospital, Queensland Health

KH, a 38 year old female presented 9 days postpartum with left upper quadrant abdominal pain. Her pregnancy was complicated by gestational thrombocytopaenia and shoulder dystocia during vaginal delivery.

She had a background of attention deficit hyperactivity disorder. Her obstetric history was G7P4T2M1 with a previous postpartum haemorrhage in 2017. Her medications included lisdexamfetamine 50 mg mane, clexane 60 mg mane and ferrous sulphate 325 mg mane.

KH had been incarcerated since her second trimester and was an ex-smoker. She denied alcohol or recreational drug use. There was no family history of autoimmune or thrombophilic disorders.

KH reported fluctuating left abdominal pain one month prepartum but had not notified staff. At day 9 postpartum, she felt a sudden onset of shooting pain in the left upper abdomen associated with vomiting. There was no history of trauma or vaginal bleeding.

She had a blood pressure of 159/107 mmHg and a low-grade temperature of 37.8 degrees Celsius. On palpation, her abdomen was soft but tender at the left upper quadrant with guarding. Her cardiovascular examination was unremarkable. She was hyperreflexic with no clonus.

Investigations included a haemoglobin of 148 g/L and platelets of 228 10^9 /L with a normal blood film and coagulation profile. Her urine protein creatinine ratio was 26 g/mol. Computed tomography (CT) of her abdomen showed multiple hypodense regions within the spleen, suspicious of splenic infarcts. Autoimmune, infectious and antiphospholipid screens were negative. She had a normal echocardiogram with no evidence of atrial fibrillation on telemetry. CT angiogram demonstrated dissection of the splenic artery and luminal narrowing of the left vertebral artery at the level of C2/3.

Multidisciplinary input was sought with advice from vascular medicine and surgery. KH was commenced on warfarin. Blood pressure control in the setting of pre-eclampsia was also prioritised. She is planned for follow-up six week progress imaging.

Splenic infarcts are rare events and generally occur in embolic or hypercoagulable states¹. There is no consensus as to the diagnostic workup or therapeutic approach¹. Previous reported cases of postpartum splenic infarcts have been associated with infection such as bacterial endocarditis² or in the setting of rheumatological³ or haematological conditions. Preeclampsia is associated with vascular dissections and aneurysms⁴. We present this rare case of splenic infarcts associated with a splenic artery dissection in a patient with pre-eclampsia and no history of pre-existing thrombophilia, connective tissue or autoimmune disorder.

1. O'Donnell M, Shatzel JJ, Olson SR, et al. Arterial thrombosis in unusual sites: A practical review. Eur J Haematol. 2018;101(6):728–736. doi:10.1111/ejh.13165

2. Siva S, Smoleniec J. Splenic infarction in pregnancy. Aust N Z J Obstet Gynaecol. 1999;39(2):252–254. doi:10.1111/j.1479-828x.1999.tb03385.x

3. Soy M, Sayin NC, Unlü E. Splenic infarction in a pregnant woman with systemic lupus erythematosus. Clin Rheumatol. 2005;24(6):663–664. doi:10.1007/s10067-004-1069-2

4. Hunsaker DM, Turner S, Hunsaker JC 3rd. Sudden and unexpected death resulting from splenic artery aneurysm rupture: two case reports of pregnancy-related fatal rupture of splenic artery aneurysm. Am J Forensic Med Pathol. 2002;23(4):338–341. doi:10.1097/00000433-200212000-00007

66: Catastrophic anti-phospholipid syndrome (APLS) in pregnancy

Sehrish Qureshi¹, Gauthami Bhagwanani¹

1. Liverpool Hospital SWSLHD, Smithfield, NSW, Australia

Dr Sehrish Qureshi , Dr Gauthami Bhagwanani Professor Jon Hyett Dr Luiza Peculis Department of Obstetrics and Gynaecology Liverpool Hospital Australia

Dr Renuka Shanmugalingam Department of Renal Medicine Liverpool Hospital Australia

Dr Penny Motum, Danny Hsu Department of Haematology Liverpool Hospital Australia

Background: Catastrophic Anti-phospholipid syndrome (APLS) is an uncommon but most severe form of APLS occurring in less than 1% of people affected by APLS yet the mortality rate is significantly high, up to 33%.

APLS in pregnancy is characterized by the presence of autoantibodies that are directed against phospholipid-binding proteins. The hallmark of APLS comprises the presence of persistent antiphospholipid antibodies (APLA) in the setting of arterial and venous thrombus and/or pregnancy loss.

Diagnosis of catastrophic APLS is based on the clinical involvement of at least three organ systems over a period of less than 1 week, with histopathological evidence of small-vessel occlusion and serological confirmation of the presence of APLS or lupus anticoagulant with high titre levels

The most common complications of APLS in pregnancy include recurrent miscarriages, pre-eclampsia/eclampsia, HELLP syndrome, placental insufficiency, prematurity, intrauterine growth restriction, fetal distress, fetal or neonatal thrombosis and arterial or venous thrombosis.

Keywords ; Catastrophic antiphospholipid syndrome; fetal distress; thrombus ; eclampsia

Case Presentation: Ms C, a 29 year old, G3P0 at 18 + 6 weeks gestation who presented with right upper quadrant pleurtic pain on the background of known triple antibody positive APLS following a previous left iliofemoral deep vein thrombosis (DVT) and pulmonary embolus (PE) She was on therapeutic clexane at a daily dose of 1.5 mg/kg whilst pregnant.

A Computed tomography pulmonary angiogram (CTPA) was negative for PE, but revealed the presence of hepatic infarcts. She also incidentally was found to be positive for Covid-19 at the time of admission. She had significantly impaired sflt1/plgf ratio which suggested placental dysfunction. Her liver function tests were also deranged. An ultrasound showed evidence of fetal growth restriction, with an estimated fetal weight less than 5%.

Ms C was managed with plasmapheresis, intravenous immunoglobulins and prednisone.

Following extensive counselling, a surgical termination of pregnancy was decided on based on the severity of her illness and the anticipated poor obstetric outcome.

Conclusion: APLS in pregnancy can have severe consequences and requires prompt treatment.

1. Catastrophic antiphospholipid syndrome in pregnancy: a life-threatening condition | BMJ Case Reports

2. Catastrophic antiphospholipid syndrome and pregnancy. Clinical report - PubMed (nih.gov)

67: The detection of occult maternal malignancy on cell-free DNA prenatal testing

Jennifer Wright¹, Graham Lieschke², Julia Unterscheider^1,3

1. Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia

2. Department of Clinical Haematology, Peter MacCallum Cancer Center/Royal Melbourne Hospital, Melbourne, VIC, Australia

3. Department of Obstetrics & Gynaecology, University of Melbourne, Parkville, VIC, Australia

Fetal chromosomal aneuploidy screening with non-invasive techniques identifying cell-free DNA in the maternal circulation from as early as 10 weeks’ gestation is increasingly utilised as a primary screening modality in obstetric practice. While the purpose of the test is aimed at the identification of placental-derived DNA to inform the fetal risk of aneuploidy, it is estimated that 1 in 12,500 NIPT tests will detect circulating tumour DNA allowing for the early detection of occult maternal malignancies.

We present the case of a 25 year-old G2P1 who undertook aneuploidy screening with primary non-invasive prenatal testing (NIPT; percept) at 11 ^+ 2 weeks gestation. Results were consistent with the presence of several segmental and whole chromosome changes and a referral to oncology was made to assess the patient for occult maternal malignancy. A breast and abdominal sonogram were unremarkable; a maternal transthoracic echo confirmed normal systolic function. A low dose FDG PET scan demonstrated FDG-avid left cervical and mediastinal lymphadenopathy, concerning for lymphoma. At 14 ^+ 2 weeks’ gestation, cervical lymph node biopsy confirmed nodular sclerosis classical Hodgkin lymphoma. Her disease was stage 2A, with Hasenclever International Prognostic Score = 1. ABVD chemotherapy was commenced at 17 weeks with intent of treating to 6 cycles. Interim re-staging by shielded CT after cycle 2 showed a good mediastinal but lesser cervical structural response. Three more cycle of AVD chemotherapy were administered during pregnancy. The pregnancy was complicated by a SARS-CoV-2 infection at 34 weeks with a mild course. Serial ultrasound scans confirmed fetal well-being and an induction of labour was planned in a timed manner at 38 ^+ 1 weeks; a female infant weighing 3390 g was delivered in good condition by vaginal birth. The patient chose to formula feed. A restaging PET scan 2 weeks postpartum demonstrated significant residual cervical disease with minimal response to treatment. Following oncology MDT discussion, the consensus was for second line treatment comprising salvage chemotherapy (ICE), autograft following response, and consideration of radiation therapy to the cervical mass. The risks of treatment including premature ovarian failure and infertility, and options for fertility preservation including Zoladex (GnRH agonist) injection, egg/embryo freezing or ovarian tissue cryopreservation were discussed. The patient chose the latter option. At time of abstract submission, the patient had received her first cycle of salvage chemotherapy.

68: Clinical Conundrums: A broken heart, a big adrenal and a baby

Jennifer Wright¹, Nayomi Perera², Julia Unterscheider^1,3, Sarah Price^4,5

1. Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia

2. Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, VIC, Australia

3. Department of Obstetrics & Gynaecology, University of Melbourne, Parkville, VIC, Australia

4. Department of Obstetric Medicine, Royal Women's Hospital, Parkville, VIC, Australia

5. Department of Medicine, University of Melbourne, Parkville, VIC, Australia

We present the case of a 24 year-old G3P2 ^+ 1−1 Afghan refugee who booked in at 28 weeks’ gestation for antenatal care after recent immigration to Australia. She had a previous Caesarean section for twins in 2018, with death of twin 1 in the neonatal period secondary to a presumed cardiac arrhythmia. A subsequent vaginal birth in 2021 was uneventful. Her only medical history was hypertension in her previous pregnancies. Early antenatal history is uncertain but she reports methyldopa use until she arrived in Australia.

At 31 weeks’ gestation, she presented to the emergency department with headache. She was normotensive and investigations excluded pre-eclampsia. At 38 ^+ 4 weeks gestation she presented in spontaneous labour. After eight hours, she was noted to be clammy, sweaty and complained of abdominal pain. Prolonged fetal bradycardia prompted an emergency Caesarean section under general anaesthetic for suspected scar rupture.

Intra-operatively, she was profoundly hypertensive with 10 min of narrow complex tachyarrhythmia and a short run of ventricular tachycardia that was not concordant with surgical stimulus. The tachyarrhythmia and hypertension responded briskly to intravenous labetalol and the response was sustained. A live female infant weighing 3.93 kg was delivered in good condition. Delivery was complicated by a 2-litre postpartum haemorrhage.

Day 1 post-partum blood pressure remained in the low-normal range (110/65 mmHg). Heart rate and rhythm were unremarkable (81bpm sinus rhythm). However, she was intermittently sweaty and flushed. A secondary hypertension screen was performed. Troponin was acutely elevated (2 > 1596 > 93 ng/L) and transthoracic echocardiogram showed mild to moderate segmental systolic dysfunction and akinesis of inferoseptal and anteroseptal wall segments consistent with Takotsubo cardiomyopathy. CT coronary angiogram showed entirely normal coronary vessels. Metoprolol was commenced.

Day 4 post-partum, secondary hypertension was returned showing markedly elevated plasma metanephrines (normetanephrine >26,093 pmol/L (N < 900); metanephrine 70pmol/L (N < 500); 3-methoxytyramine >1,609pmol/L (N < 110)). CT CAP revealed a 45 mm left adrenal mass and 15 mm right aortocaval lesion suggestive of either paraganglioma or phaeochromocytoma with metastases. Solid pulmonary nodules were noted through-out bilateral lungs. Gatate PET scan was arranged. At the time of abstract submission, the result of this study was pending. Metoprolol was discontinued and prazosin commenced to achieve alpha blockade in preparation for potential surgery on the adrenal mass. Genetic testing was arranged.

This case demonstrates the diagnostic challenge of catecholamine secreting neuroendocrine tumours in pregnancy. It presents an opportunity for discussion around management in pregnancy and the early post-partum period.

69: Deliberate self-harm in pregnancy – a case series

Audrin Lenin¹, Sowmya Sathyendra¹, Sudha Jasmine Rajan¹

1. Christian Medical College, Vellore, Vellore, TAMIL NADU, India

Background: Deliberate self-harm (DSH) in pregnancy is the tip of the larger under-recognized iceberg of peripartum depression. Deliberate self-harm in pregnancy, though rare is an important condition as it affects the lives of the mother and the foetus, and this results in challenges in management.

Aim: To look at the clinical profile and outcomes in patients presenting with DSH in pregnancy from 2009 to 2021 admitted under a single medical unit in a tertiary centre in South India.

Methods: A retrospective chart and discharge summary review was conducted for the patients admitted with DSH in pregnancy. The demographic data, type of compound consumed, psychiatric background, clinical and obstetrical outcomes were analysed.

Results: There were 12 patients who were admitted with history of DSH in pregnancy from 2009 to 2021. 66% of the patients were in the 2^nd trimester. Medication overdose was the most common mode of DSH and only 33% of the patients had clinical features of toxicity. There were no deaths or residual morbidity. Only one patient came for delivery in CMC, and she did not have any obstetrical or neonatal complications.

Conclusion: DSH in pregnancy is a rare, but preventable condition. The medications which the patient is already taking are the most common compound. The lack of follow up among the patients admitted with DSH was an eye-opener. Patients with DSH planned for telephonic follow up by social worker. There is a need to look at the various social, psychological and health factors which predispose a pregnant woman to attempt deliberate self-harm.

1. Arachchi, N.S.M., Ganegama, R., Husna, A.W.F. et al. Suicidal ideation and intentional self-harm in pregnancy as a neglected agenda in maternal health; an experience from rural Sri Lanka. Reprod Health 16, 166 (2019). https://doi.org/10.1186/s12978-019-0823-5

2. Catherine MacLeod Hall, Emma Molyneaux, Hannah Gordon, Kylee Trevillion, Paul Moran, Louise M. Howard, The association between a history of self-harm and mental disorders in pregnancy, Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2019.06.062.

70: Risk factors for antenatal depression in a developing country: A cross sectional Study

Sudha Jasmine Rajan¹, PhebyMercy Bijoy¹, Grace J Rebekah¹, Reeta Vijayaselvi¹, Suja Kurien¹, audrin lenin¹

1. Christian Medical College, Vellore, Vellore, TAMIL NADU, India

Antenatal depression is a common health problem that is neglected in developing countries. The aim was to estimate the prevalence, risk factors and implications of antenatal depression among those with and without medical comorbid illnesses, as that has not been studied much in the developing countries. The stigma with mental health problems precludes referral to available mental health professionals. We aimed to develop a screening system for appropriate referral.

This cross-sectional study was done among women attending the Obstetric Medicine Clinic and the regular antenatal clinic at a tertiary care university teaching hospital. 291 patients were consecutively recruited from the Obstetric Medicine Clinic (148) and from the Antenatal clinics (143) after informed consent if they were more than 18 years and were able to read and write the vernacular or English language. Sample size was calculated based on a pilot study that found 20% prevalence of depression among women with medical comorbidities, assuming 10% among those without comorbidities with power at 80% and alpha error at 5% for a two-sided test to be 199 in each group. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for depression and the Beck's Depression Inventory to assess severity. The maternal and foetal outcomes were obtained from hospital electronic records. Epi data form was used for data entry and SPSS version 21 for analysis. The study was approved by the institutional review board in August 2019. IRB Min No: 10161 dated 06.08.2019

24.3% had scored 11 or higher on the EPDS, reflecting a high likelihood of depression. 10.5% had a score >20 on Beck`s depression inventory suggestive of moderate to severe depression. Domestic violence [OR 4.4171(95%CI 1.58–12.34)], Marital conflict [OR – 2.977 (95%CI 1.103–8.037)], smoking in the partner or a family member [OR- 3.328 (95%CI 1.125–9.842)], family expectations regarding the gender of the baby [ OR – 2.071 (95% CI 1.075–3.990)] and unplanned pregnancy[OR 2.0540 (95%CI 1.19–3.55)(p = 0.009)] were associated with a higher risk for depression in both groups. On multivariate regression, spouse staying with the woman was protective OR 0.284 (95% CI 0.20–0.4) (p < 0.001) and domestic violence, an independent risk factor OR 3.475(95% CI 1.208–9.998) (p = 0.021)for depression.

Social factors play a crucial role in maternal mental health. Social history is essential to identify those at risk and to provide adequate management of antenatal depression.

71: Primary hyperparathyroidism in pregnancy; challenges in work up and management

Nayomi D Perera¹, Damien Qi¹, Sarah Price^1,2

1. Diabetes and Endocrinology, Royal Melbourne Hospital, Parkville, VIC, Australia

2. Obstetric Medicine, Royal Women's Hospital, Parkville, Victoria, Australia

Case presentation: 28 Prim gravid, 29+/40 was noted to have hypercalcemia with a corrected calcium (cCa) of 2.96 whilst being investigated for muscle cramps. Further history revealed fatigue, urinary frequency and constipation which the patient had attributed to physiological response of pregnancy. Pregnancy had otherwise been uncomplicated. Medical history included hypothyroidism. Regular medications included levothyroxine 100 mcg/50 mcg alternate daily, Elevit, Gaviscon. On repeat testing, cCa 3.07, prompting admission for intravenous fluid therapy. Further investigations were consistent with primary hyperparathyroidism (parathyroid hormone 18.5 and ultrasound revealing a 15 mm parathyroid nodule. Endocrine surgical team strongly recommended 4DCT imaging for surgical planning, but was later rationalised give radiation exposure. The patient was transferred to a tertiary centre where medical management continued with hydration, calcitonin and frusemide until 37 + 4 weeks gestation (in the setting of a negative preeclampsia risk test (PERT)). Post-partum there was transient fetal hypocalcemia and patient underwent an uncomplicated parathyroidectomy, with no post-operative hypercalcaemic crisis. Our patient has been referred for genetic testing to exclude an underlying genetic syndrome such as MEN1/2A.

Discussion: Primary hyperparathyroidism (PHPT) in pregnancy may be difficult to diagnose given the nature of its vague symptoms; including asymptomatic, hyperemesis gravidarum, fatigue, polyuria and emotional lability (1). Untreated PHPT, or hypercalcaemia of any cause can have significant maternal and fetal complications (2), including pre-eclampsia (25%), and this risk remains elevated for 5 years, even despite surgical removal of parathyroid (3), increased risk of miscarriage and fetal death in utero (2).

Differentials for hypercalcemia include PTH dependant and PTH independent causes. Appropriate work-up of hypercalcemia includes reviewing causative medications (i.e. in this patient including elevit, cholecalciferol), biochemistry, urinary calcium to assess for familial hypocalcuric hypercalemia and radiology if indication. Imaging choice to localise a possible parathyroid adenoma need so be rationalised against radiation exposure in these young females; with radiological options include of US, nuclear medicine sestimibi, standard CT neck and newer 4DCT carrying radiation exposure of 0 mGy, 11 mGy, 60–75 mGy and 150 mGy respectively (4).

No formal guidelines exist regarding that management of primary hyperparathyroidism. Management options including medical management include cessation of causative medications, intravenous fluid therapy, frusemide and calcitonin (1). Operative management remains the definitive treatment option when a parathyroid adenoma is suspected. Operative timing in second trimester is preferred, however abnormal PERT test may require surgical intervention in third trimester (1). Meta-analysis revealed no major adverse outcomes in 15 individuals who underwent parathyroidectomy in third trimester (5).

1. Dandurand K, Khan AA. Hypercalcemia in pregnancy. Endocrinol Metab Clin N Am 50 (2021) 753–768. 3–768 https://doi.org/10.1016/j.ecl.2021.07.009

2. Cetani F, Saponaro F, Marcocci C. Non-surgical management of primary hyperparathyroidism. Best Pract Res Clin Endocrinol Metab. 2018;32(6):821–835

3. Hultin H, Hellman P, Lundgren E, et al. Association of parathyroid adenoma and pregnancy with preeclampsia. J Clin Endocrinol Metab 2009;94(9):3394–9.

4. Hubbard P., Callahn J., Cramb J., Budd R., Kron T. Audit of radiation dose delivered in time-resolved four-dimensional computed tomography in a radiotherapy department. J Med Imag Radiat Oncol. 2015;59:346–352

5. Constantinos Nastos, Anna Paspala et al. (2021) Surgical management of primary hyperparathyroidism during pregnancy: a systematic review of the literature, Gynecological Endocrinology, 37:12, 1086–1095, DOI: 10.1080/09513590.2021.1932801

72: Pulmonary hypertension in pregnancy: a case of newly diagnosed pulmonary hypertension in a concealed pregnancy

Paige Hansen ¹

1. Obstetrics and Gynaecology, Royal Hobart Hospital, Hobart, Tasmania, Australia

Pulmonary hypertension (PH) is considered a contraindication to pregnancy (1). The maternal mortality rate with PH has been reported up to 30–56% (2). Below, we discuss the new diagnosis of PH, likely secondary to rheumatic heart disease, in a concealed pregnancy.

A 23-year-old multigravida Tongan woman presented with a one week history of shortness of breath, haemoptysis and bilateral lower limb oedema. She was covid positive and incidentally found to have a gravid uterus confirmed on USS to be approximately 36 weeks gestation. There was no significant past medical history. On examination she was tachycardic and tachypnoeic with increased work of breathing, diffuse crepitations and pitting oedema to mid shins.

A Chest x-ray showed massive cardiomegaly and bilateral consolidation. An echocardiogram showed global dilatation, with significant mitral regurgitation, a severely thickened mitral valve with stenosis, severe tricuspid regurgitation and a pulmonary pressure of 63 mmHg. She was treated with dexamethasone, diuretics, remdesivir and benzyl penicillin/azithromycin for associated COVID pneumonia.

She had spontaneous rupture of membranes at 36 + weeks and she was transferred to a tertiary centre. Her case was discussed with Maternal Fetal medicine specialists and a cardiac obstetric anaesthetist. The intensive care team, paediatrics, anaesthetics, cardiology and the infectious diseases team were all notified of her impending arrival. A plan was made for a vaginal delivery with regional anaesthetic, given the advantage of vasodilation, and a short second stage with instrumental delivery if needed. Avoid oxytocics due to risk of pulmonary vasoconstriction.

She started contracting at 0400 the following day. She had an early epidural and insertion of an arterial line. Her contractions became 1 in 10 min. it was thought important to encourage delivery rather than expectant management with the hope for delivery during daytime hours. She was given misoprostal 50 mcg at 1330 for augmentation.

Her labour then progressed well, she pushed with good decent and a 15 min second stage without assistance. Baby was born in good condition, there was brisk loss at birth. Bleeding was managed with 2 units of IM syntocinon and 1 g IV tranexamic acid. Her post partum course was fortunately uneventful with ICU and cardiology input. She was referred for cardiac valve surgery.

The cardiovascular demands of pregnancy are often not met by women with PH (3). This can present with shortness of breath and oedema but can lead to devasting outcomes if not appropriately managed by a multidisciplinary team.

1. Pieper, P G, and E S Hoendermis. “Pregnancy in women with pulmonary hypertension.” Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation vol. 19,12 (2011): 504–8. doi:10.1007/s12471-011-0219-9

2. Hemnes, Anna R., et al. “Statement on Pregnancy in Pulmonary Hypertension from the Pulmonary Vascular Research Institute.” Pulmonary Circulation, vol. 5, no. 3, 2015, pp. 435–65. JSTOR, https://doi.org/10.1086/682230. Accessed 16 Jun. 2022.

3. Kiely, David G et al. “Pregnancy and pulmonary hypertension: a practical approach to management.” Obstetric medicine vol. 6,4 (2013): 144–54. doi:10.1177/1753495X13495193

73: COVID-19 In January 2022 with the Omicron wave – How does it affect mothers and babies?

Rebecca Y Li¹, Jessica Zhang², Karen Harris¹

1. Department of O&G, Bankstown Hospital, Bankstown, NSW, Australia

2. School of Medicine, University of New South Wales, Kensington, NSW, Australia

Introduction: Coronavirus disease 2019 (COVID-19) can result in both symptomatic and asymptomatic infections (1). The physiological changes in pregnancy with respect to the immune and respiratory systems increases the susceptibility of infections in pregnancy (2). Vaccination reduces the risk of developing COVID-19 and reduces the severity of disease if an infection occurs. Multiple studies have demonstrated that COVID-19 can have adverse maternal and perinatal outcomes including preterm delivery, admission to intensive care and the neonatal unit and stillbirth (2). However, these studies were all from outbreaks in 2021, and where vaccination against COVID-19 was not readily available. It was thought that cardiotocography (CTG) abnormalities during labour, the presence of meconium and chorioamnionitis was increased in those with COVID-19 anecdotally.

Objective: To determine if mild COVID-19 infection during pregnancy in Jan 2022 is associated with increased risks of adverse maternal and perinatal outcomes.

Methods: A retrospective cohort study was conducted on 136 completed pregnancies at a secondary Sydney hospital which delivered between 1 to 31 of Jan 2022. The cases of those that had COVID-19 in pregnancy were compared to those that were unaffected. Secondary outcomes of CTG abnormalities during labour, meconium and placental histopathology was compared between those that has COVID-19 at any stage in pregnancy with the unaffected.

Results: In the studied cohort, only 57% were double vaccinated. 43% (59 cases) tested positive to SARS-Cov-2 during their pregnancy, with the majority in their third trimester. Of those that had COVID-19, 49% were double vaccinated, and only 1 patient had had a booster, 73% had mild symptoms with the main symptom being cough, no one had severe symptoms and 27% were asymptomatic. There were no cases of stillbirth or neonatal death. There were two cases of maternal admissions to intensive care, however their admissions were due to monitoring after severe postpartum haemorrhage and not for respiratory support. Only 7% of those with COVID-19 had acute chorioamnionitis on placental histopathology and having COVID-19 did not increase the risk of having meconium. Those with COVID-19 were more likely to have CTG abnormalities than the unaffected by 19 percentage points (p value <0.05).

Conclusion: The omicron wave of COVID-19 from January 2022 causes a milder or asymptomatic infection. Those with COVID-19 in any stage in pregnancy were more likely to have CTG abnormalities in labour. Thus, it is essential that those that with COVID-19 in pregnancy have continuous electronic foetal monitoring in labour.

1. Berghella V, Hughes BL, 2022, UpToDate - COVID-19: Overview of pregnancy issues, Last updated 8 June 2022, From: https://www.uptodate.com/contents/covid-19-overview-of-pregnancy-issues

2. Zaigham M, Andersson O, 2020, Maternal and perinatal outcomes with COVID-19: A systematic review of 108 pregnancies, Acta Obstet Gynecol Scand, 99:823–829

74: Infant exposure to armodafinil through breast milk following maternal use of modafinil

Catherine E Leggett¹, Usha Ritchie², Lynn Costi¹, David Elliot³, Arduino A Mangoni^3,4, Bill M Hague⁵

1. Women's and Children's Health Network, SA Pharmacy, North Adelaide, South Australia, Australia

2. Central Adelaide Local Health Network, SA Pharmacy, Adelaide, South Australia, Australia

3. Department of Clinical Pharmacology, Flinders Medical Centre, Bedford Park, South Australia, Australia

4. Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia

5. Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia

Introduction: Narcolepsy, a condition that adversely affects psychological, social, and cognitive function, is more prevalent in women of childbearing age than in the general population. Modafinil and armodafinil are central nervous system stimulants approved for the treatment of narcolepsy. However, infant exposure to these agents through breast milk has not been investigated. We studied this issue in a 30-year-old woman with narcolepsy who was taking modafinil (300 mg morning, 100 mg midday) while exclusively breastfeeding her 6-week-old infant.

Aim: To measure the concentration of armodafinil, the active enantiomer of modafinil, in breast milk and quantify infant exposure.

Method: Eight breast milk samples were collected over a 26-h period along with a single paired maternal plasma sample and one infant plasma sample. Breast milk and plasma concentrations of armodafinil were analysed using ultra performance liquid chromatography - tandem mass spectrometry (UPLC-MS) and based on a validated assay.

Results: The average concentration of armodafinil in breast milk was 1.96 mg/L, and the relative infant dose was 4.85% of the weight-adjusted maternal dose. The theoretical infant dose of armodafinil was 0.294 mg/kg/day and maternal and infant plasma concentrations were 12.02 mg/L and 0.19 mg/L, respectively. The infant was reported to have normal growth and development at the time of study.

Discussion: Our case demonstrates the presence of very low concentrations of armodafinil in infant plasma following maternal use of the parent drug modafinil at the maximum recommended daily dose. The calculated relative infant dose was below the nominal safety threshold of 10%¹ and the theoretical infant dose was approximately 10 times less than a weight-based dose for a 70 kg adult receiving 150–250 mg of armodafinil daily. Equally reassuringly, the infant plasma level was also much less than the published peak steady state concentrations of armodafinil (0.9 to 3.3 mg/mL) in adults following administration of modafinil 100 mg twice daily.

Conclusion: Relatively small amounts of armodafinil pass into breast milk, with consequent limited infant exposure. Consideration can be given to the use of modafinil or armodafinil during breastfeeding provided the infant is monitored.

1. Hale, T. W. (2020). Hale's Medications & Mothers’ Milk 2021: A Manual of Lactational Pharmacology. Springer Publishing Company.

75: Cardiovascular screening of women with past pre-eclampsia and gestational hypertension: The western health survey of heart failure risk after pregnancy hypertension (WHAT RISK) pilot survey

Jonathan JS Sen¹, Jordan JD Dixon², Emma ES Smith², Sam SB Banks², Ashleigh-Georgia AGS Sheriff¹, Lee-Anne LAL Lynch², Leah LW Wright¹, Joanne JS Said², Tom TM Marwick¹

1. Baker Heart and Diabetes Institute, Melbourne

2. Western Health, St Albans, VICTORIA, Australia

Background: Despite resolution of hypertension following delivery, could the metabolic and cardiovascular changes during pregnancy be leading to significant cardiovascular sequelae?

Objective: To determine a difference in the metabolic and biochemical profile of women who have pre-eclampsia compared to those with gestational hypertension (GHT). We hypothesise that women who experienced pre-eclampsia 5–10 years previously are more likely to have adverse metabolic profiles compared with women who experienced GHT.

Design: Retrospective case-control study.

Participants: Women with a history of pre-eclampsia or GHT who are now 5–10 years postpartum. Women were excluded if they had pre-existing diabetes or known cardiovascular disease prior to the pregnancy.

Methods: Eligible participants who birthed at Sunshine Hospital, Western Health between 2011 and 2016 were identified via the Birthing Outcomes System (BOS) with eligibility confirmed by review of electronic and digital medical records. Women were contacted and invited to attend for an assessment of their cardiovascular risk profile (based on cardiovascular risk factors on history and examination), blood pressure and biochemical data. Subgroup analysis of these parameters was performed between women with pre-eclampsia and GHT. Continuous variables were compared using ANOVA while dichotomous variables were compared utilising fisher exact tests.

Results: 15 women with a history of GHT and 25 women with pre-eclampsia were recruited. At delivery, women with pre-eclampsia were significantly more likely to have higher mean systolic (166 vs 153 p = 0.015), and diastolic blood pressure (101.7 vs 91.9 p = 0.0147) along with higher levels of uric acid (0.41 vs 0.34 p = 0.03), compared to those with GHT. There was no statistically significant difference at delivery in proteinuria, creatinine, bilirubin, AST or ALT. Women with a history of pre-eclampsia were significantly more likely to have higher levels of chloride (104.71 vs 104.17 p = 0.0469), creatinine (62.48 vs 61.75 p = 0.01), and urea (4.4 vs 4.7 p = 0.0002) compared to women with GHT 5–10 years post-partum. There were no statistically significant differences 5–10 years later in systolic or diastolic blood pressure, total cholesterol triglycerides, HDL, LDL, non-HDL, sodium, potassium, bicarbonate, eGFR, HBA1c, blood glucose, smoking and alcohol intake.

Conclusion: This observational study did not identify any significant differences in the metabolic profile between women who experienced pre-eclampsia and those who had GHT 5–10 years earlier. Further studies should include a control group of women who experienced uncomplicated pregnancies to determine whether the metabolic profile of women who experienced any hypertensive disorder during pregnancy differs from those who are normotensive throughout pregnancy

76: The conundrum of defining and measuring maternal morbidity

Joanne Frost¹, Leonie Callaway^2,1, Edward Weaver^3,4

1. Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia

2. Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia

3. Department of Obstetrics and Gynaecology, Sunshine Coast University Hospital, Birtinya, QLD, Australia

4. School of Medicine and Dentistry, Griffith University, Sunshine Coast, QLD, Australia

Maternal mortality, the most severe adverse outcome for a woman related to pregnancy, has traditionally been used as a marker of the quality and safety of maternity health care. Throughout Australia, there is a systematic approach to examining and reporting maternal mortality. This enables identification of contributing factors to improve outcomes. In developed countries where maternal mortality rates are low, maternal morbidity may be a more important indicator of quality health care (1).

However, there is no consistent, systematic approach to examining maternal morbidity. Worldwide, short and long term impairment as a result of pregnancy, and the ensuing impact this has on women and their families is largely unknown. It is commonly quoted that for every maternal death there are 20–30 cases of acute or chronic maternal morbidity, but the validity of this is unclear (12,3).

In Australia, maternal morbidity burden is inconsistently recorded in each state, contributing to limited national data. Thus, we do not know the extent to which maternal morbidity impacts the physical and mental health of women, maternity care providers and the health care system in Australia. This is an important gap in our quality assurance systems.

As part of the work of the Queensland Maternal and Perinatal Quality Council, we are working towards a better understanding of maternal morbidity. However, we have discovered that a key challenge in collecting data regarding maternal morbidity is that it is difficult to define.

In this presentation, we will explore the various ways of defining maternal morbidity and consider the advantages and disadvantages of each definition. Standardisation of the definition of maternal morbidity is an essential first step if we wish to systematically examine maternal morbidity, to improve the care we provide to Australian women and their families.

1. Firoz T, Chou D, von Dadelszen P, Agrawal P, Vanderkruik R, Tunçalp O, et al. Measuring maternal health: focus on maternal morbidity. Bulletin of the World Health Organization. 2013;91(10):794–6.

2. Chou D, Tunçalp Ö, Firoz T, Barreix M, Filippi V, von Dadelszen P, et al. Constructing maternal morbidity – towards a standard tool to measure and monitor maternal health beyond mortality. BMC Pregnancy Childbirth. 2016;16(1):45.

3. Vanderkruik RC, Tunçalp Ö, Chou D, Say L. Framing maternal morbidity: WHO scoping exercise. BMC Pregnancy Childbirth. 2013;13:213.

77: Discordant NIPS results associated with maternal malignancy in pregnancy: an underutilised diagnostic tool?

Harriet L Calvert¹, Ailsa Borbolla Foster¹

1. Hunter New England Local Health District, Kotara, NSW, Australia

Background: A new diagnosis of maternal malignancy during pregnancy is rare with a reported incidence of 0.1%. (1). The most common malignancies diagnosed are breast, cervical, lymphoma, melanoma, leukaemia, ovarian & colorectal cancers (1). NIPS utilises sequencing and bioinformatics algorithms to interrogate maternal and placental cell-free DNA fragments extracted from maternal blood. Biological explanations for inaccurate NIPS results include: confined placental mosaicism, vanishing twin syndrome, maternal chromosomal mosaicism, DNA copy-number variants, maternal organ transplantation and maternal malignancy (2). Maternal malignancy was first reported as a reason for NIPS discordance in 2013 due to abnormal DNA fragments released from apoptotic cancer cells (3). Based on results from a 2015 study it was estimated that between 20–44% of discordant NIPS and fetal karyotype results were due to an occult maternal malignancy (2). Dharajiya et al. found that of 450,000 pregnant patients who had NIPS: 41.9% of unreportable results were attributed to maternal malignancy (4). Abnormal cfDNA patterns have been found in more than 80% of patients with known metastatic solid tumor cases and 50% of localized cancers (5).

Cases: We report 3 cases of a new diagnosis of maternal malignancy in pregnancy with abnormal NIPS results. In just one case the malignancy was diagnosed after investigation stemming from the abnormal NIPS. Our first case is a 26 year old primigravida diagnosed with Hodgkin's lymphoma at 21 + 4 who had an unreportable NIPS at 12 + 3 despite adequate fetal fraction. Our second case is a 34 year old primigravida who was diagnosed at 23 weeks with high-grade B-cell lymphoma who had a NIPS at 16 + 2 with multiple aneuploidies detected but normal fetal microarray at amniocentesis. Our third case is a 38 year old multigravida diagnosed colorectal adenocarcinoma at 16 weeks after having an unreportable NIPS at 12 weeks followed by a repeat NIPS at 14 weeks showing multiple maternal acquired chromosomal copy number changes.

Discussion: We will highlight an approach to follow-up of unreported NIPS with adequate fetal fraction or abnormal NIPS with discordant fetal karyotype. This includes comprehensive maternal medical history and examination with a view to proceeding stepwise with further investigations for possible malignancy. There should be a high index of suspicion as earlier diagnosis and treatment may improve survival. Multi-disciplinary team involvement is paramount, and Obstetricians should be familiar with counselling of women with discordant or unreportable NIPS results.

78: Retrospective cohort study examining the frequency and time course of COVID-19 symptoms in pregnancy during the Omicron wave from January-May 2022 in a large metropolitan Melbourne tertiary hospital

Dimity Archer¹, Joanne Said^1,2, Su Lynn Khong¹, Elise Regan- Gomm¹, Lee-Anne Lynch ¹

1. Western Health, Footscray, VIC, Australia

2. University of Melbourne, Melbourne, Victoria, Australia

Background: COVID-19 infection in pregnancy is associated with increased maternal mortality and ICU admissions(1), higher rates of preterm birth and caesarean section(2), largely based on data obtained during the first 18 months of the pandemic, where the Alpha and Delta strains predominated. A significant number of pregnant women were infected with COVID-19 during the Omicron wave, which was prevalent in Melbourne from January-May 2022. Concomitantly, vaccination rates amongst pregnant women were increasing but remained lower than non-pregnant populations(3). There is a paucity of data regarding the prevalence and time course of symptoms of the Omicron variant of COVID-19 in pregnant women.

Aim: The primary aim was to assess the frequency and time course of symptoms of COVID-19 in a pregnant population.

Study design: We analysed the symptom patterns reported by pregnant women with COVID-19 managed through the Western Health Obstetric COVID-19 home monitoring program between January-May 2022. Pregnant women referred were given the option to monitor and report their symptoms and observations daily using a survey. We reviewed the symptom pattern and trajectory daily from the date of the positive COVID-19 test to determine the frequency of each of the common COVID-19 symptoms during pregnancy.

Results: 467 women reported their symptoms at least once during the 10 days following their positive COVID-19 result. 217 women were triple vaccinated at the time of their illness, 210 had received 2 doses, 5 had received 1 dose, 34 women were unvaccinated, and 1 woman had no vaccination status recorded. The most common symptom reported was a sore throat (reported by 85% of those reporting symptoms on day 0). 252 women had access to an oxygen saturation monitor. No women reported an oxygen saturation below 94%. Tachycardia was reported on a total of 222 occasions by 96 women, and was most commonly reported on day 0. The highest rate of symptoms were reported on day 3 following the positive COVID-19 test with 99% of women reporting symptoms. Only 53% of women reported symptoms on day 7 and 35% on day 10.

Conclusion: This data provides valuable insights into the trajectory of COVID-19 symptoms and observations for pregnant women during the Omicron wave in Melbourne and confirms that the majority of pregnant women with this variant experienced mild self-limiting symptoms. This data assists in caring for pregnant women diagnosed with COVID-19 locally and improves our knowledge of duration of symptoms related to the Omicron strain.

1. WAPM (World Association of Perinatal Medicine) Working Group on COVID-19. Maternal and perinatal outcomes of pregnant women with SARS-CoV-2 infection. Ultrasound Obstet. Gynecol. 2021, 57, 232–241. Accessed 23 Jun 22. Available from: https://doi.org/10.1002/uog.23107

2. Pathirathna, M.L.; Samarasekara, B.P.P.; Dasanayake, T.S.; Saravanakumar, P.; Weerasekara, I. Adverse Perinatal Outcomes in COVID-19 Infected Pregnant Women: A Systematic Review and Meta-Analysis. Healthcare 2022, 10, 203. Accessed 23 Jun 22. Available from: https://doi.org/10.3390/healthcare10020203

3. Skjefte M, Ngirbabul M, Akeju O, Escudero D, Hernandez-Diaz S, Wyszynski D, Wu J. Covid-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries. Eur J Epidemiol. 2021 Feb;36(2):197–211. Accessed 23 Jun 22. Doi: 10.1007/s10654-021-00728-6.

79: Severe epistaxis in pregnant Jehovah's witness: A case report

Elizabeth Cobden¹, Natasha Frawley¹

1. Ballarat Health Services, Ballarat, VIC, Australia

Introduction: We report a case of severe epistaxis causing profound anaemia in pregnancy. Two challenges to care were Jehovah's witness status and anaemia induced fetal distress. Ultimately, the patient's anaemia was corrected medically without blood transfusion and she was able to progress to a term delivery.

Case: A 38 yo Jehovah's Witness (JW) presented at 32 + 5/40 with massive epistaxis refractive to standard treatment. Her pregnancy risk factors were BMI 31 and advanced maternal age. The initial presentation was spontaneous right sided epistaxis, managed with tamponade. After multiple rebleeds she was transferred to a larger regional public hospital to access ENT.

Her haemoglobin decreased from 134 g/L to 63 g/L over three days, causing dizziness, shortness of breath and fetal distress with tachycardia. The patient's advanced care directive was reviewed but the patient did not agree to blood products. Multidisciplinary discussions were held with obstetricians, ENT surgeons, haematologists, nephrologists, anaesthetics and paediatricians.

Two cauterisations were performed and rapid rhino inserted. Tranexamic acid and labetalol were prescribed.

The first issue was the patient's life-threatening anaemia. There was fetal distress but delivery would significantly risk maternal death. The anaemia was managed medically using intravenous iron (ferric carboxymaltose) and fortnightly erythropoietin.

The second issue was planning delivery. Generally, JW patients are recommended less invasive surgery, to minimise bleeding. However, there was concern that second stage of labour valsalva and hypertension may result in further nasal bleeds, and caesarean would be safer.

At 36 weeks an ultrasound showed normal growth but raised Umbilical artery doppler.

The patient had an elective Caesar at 37 + 3 with two obstetricians and cell saver. Her pre-operative haemoglobin was 114 g/L. The weighed blood loss was 312 mls.

Discussion: Epistaxis in pregnancy is reported up to 20%, but is rarely severe.(1) First line treatment includes conservative measures of packing, nasal cautery, antihypertensives and intravenous antifibrinolytics. Extreme cases in pregnancy can require nasal vessel ligation or even termination of pregnancy. Most cases reported in the literature underwent caesarean section, to reduce the risk of rebleed.(1)

Our case had the added complexity of Jehovah's witness status. Risk of maternal death rises significantly at haemoglobin levels below 60 g/L in JW.(2) In these patients, clear communication of the medical, ethical and legal implications of decisions is paramount. In patients who refuse blood products, the fastest method to optimise haemoglobin is intravenous iron alongside erythropoietin.(3) Cell saver is often acceptable to patients with JW and should be utilised where possible.(4)

1. Piccioni MG, Derme M, Salerno L, et al. Management of Severe Epistaxis during pregnancy: A Case Report and Review of Literature. Case Rep Obstetric Gynaecology. 2019;2019:5825309. Published 2019 Jan 20. dot: 10.1155/2019/5825309

2. Herbert PC, Biro GP. Review of physiological mechanisms in response to anaemia. Can Med Assoc J. 1997;156:27–40

3. Tanaka M, Matsuzaki S, Endo M, et al. Obstetric Outcomes and acceptance of alternative therapies to blood transfusion by Jehovah's Witnesses in Japan: a single-centre study. International Journal of Haematology. 2018; 108:432–437

4. Waters JH. Intraoperativr blood recovery. ASAIO J. 2013;59:11–17

80: Rifampicin - rare adverse reactions

Adam Morton ¹

1. Mater Health, Brisbane

Ursodeoxycholic acid, currently the mainstay of treatment for intrahepatic cholestasis of pregnancy (ICP), has no significant effect on stillbirth and neonatal unit admission. ^{1, 23}

Hague et al. recently described the protocol for a randomised superiority trial (TURRIFIC trial) comparing the efficacy of ursodeoxycholic acid with rifampicin in women with severe early onset ICP.⁴

Hepatotoxicity with rifampicin monotherapy has been reported in approximately 2% of patients with latent tuberculosis and 4.8% of patients with cholestatic pruritus.^{5, 6} Hepatoxicity is usually self-limiting and resolves despite continuation of treatment.⁵ Grade 3 or grade 4 hepatic failure leading to drug discontinuation was reported in 0–0.7% of individuals who received 4 months of rifampicin monotherapy for latent tuberculosis.⁷

Two small case series of rifampicin therapy in primary biliary cirrhosis however found that 5 of 57 (8.8%) patients developed significant hepatitis, onset 4–8 weeks after commencing therapy. ^{8, 9} Two patients had coagulopathy, one patient requiring liver transplantation.

Acute kidney injury has been reported in 0.1% of individuals treated with rifampicin, mechanisms including interstitial nephritis, acute tubular nephritis and proliferative crescentic glomerulonephritis.¹⁰

Fourteen cases of disseminated intravascular coagulation (DIC), including 4 deaths, have been described following ingestion of rifampicin.¹¹ Symptoms occurred within hours of rifampicin ingestion, typically in the setting of previous exposure. DIC is induced by immunoallergic reactions mediated by IgG and IgM antibodies against target cells expressing blood antigen I.

Anaphylaxis, serum sickness, autoimmune haemolytic anaemia, thrombocytopaenia and hypotension may rarely occur due to hypersensitivity reactions to rifampicin, with causation established by positive skin testing.¹² Rifampicin may also precipitate coagulopathy in the setting of vitamin K deficiency.¹³

Rifampicin has a low incidence of serious adverse effects, though close monitoring of liver function, renal function, full blood count and prothrombin time will be important for early detection. While DIC with rifampicin is extremely rare, awareness of this possibility will be important, particularly in women who have been previously exposed, given the rapidity of onset, and the risk of recurrence of ICP in subsequent pregnancies.

1. Parizek A, Simjak P, Cerny A, et al. Efficacy and safety of ursodeoxycholic acid in patients with intrahepatic cholestasis of pregnancy. Ann Hepatol 2016; 15: 757–761. 2016/08/06. DOI: 10.5604/16652681.1212562.

2. Chappell LC, Bell JL, Smith A, et al. Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial. Lancet 2019; 394: 849–860. 2019/08/06. DOI: 10.1016/S0140-6736(19)31270-X.

3. Ovadia C, Sajous J, Seed PT, et al. Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a systematic review and individual participant data meta-analysis. Lancet Gastroenterol Hepatol 2021; 6: 547–558. 2021/04/30. DOI: 10.1016/S2468-1253(21)00074-1.

4. Hague WM, Callaway L, Chambers J, et al. A multi-centre, open label, randomised, parallel-group, superiority Trial to compare the efficacy of URsodeoxycholic acid with RIFampicin in the management of women with severe early onset Intrahepatic Cholestasis of pregnancy: the TURRIFIC randomised trial. BMC Pregnancy Childbirth 2021; 21: 51. 2021/01/14. DOI: 10.1186/s12884-020-03481-y.

5. Senousy BE, Belal SI and Draganov PV. Hepatotoxic effects of therapies for tuberculosis. Nat Rev Gastroenterol Hepatol 2010; 7: 543–556. 2010/09/03. DOI: 10.1038/nrgastro.2010.134.

6. Webb GJ, Rahman SR, Levy C, et al. Low risk of hepatotoxicity from rifampicin when used for cholestatic pruritus: a cross-disease cohort study. Aliment Pharmacol Ther 2018; 47: 1213–1219. 2018/02/23. DOI: 10.1111/apt.14579.

7. Ziakas PD and Mylonakis E. 4 months of rifampin compared with 9 months of isoniazid for the management of latent tuberculosis infection: a meta-analysis and cost-effectiveness study that focuses on compliance and liver toxicity. Clin Infect Dis 2009; 49: 1883–1889. 2009/11/17. DOI: 10.1086/647944.

8. Bachs L, Pares A, Elena M, et al. Comparison of rifampicin with phenobarbitone for treatment of pruritus in biliary cirrhosis. Lancet 1989; 1: 574–576. 1989/03/18. DOI: 10.1016/s0140–6736(89)91608-5.

9. Prince MI, Burt AD and Jones DE. Hepatitis and liver dysfunction with rifampicin therapy for pruritus in primary biliary cirrhosis. Gut 2002; 50: 436–439. 2002/02/13. DOI: 10.1136/gut.50.3.436.

10. Blajchman MA, Lowry RC, Pettit JE, et al. Rifampicin-induced immune thrombocytopenia. Br Med J 1970; 3: 24–26. 1970/07/04. DOI: 10.1136/bmj.3.5713.24.

11. Sousa G, Carreiro A and Duarte P. Rifampicin-induced disseminated intravascular coagulation: An antibody-mediated side effect. Pulmonology 2020 2020/05/23. DOI: 10.1016/j.pulmoe.2020.04.006.

12. Sveroni D, Stefos A, Rigopoulou EI, et al. Rifampicin: not always an innocent drug. BMJ Case Rep 2018; 11 2018/12/21. DOI: 10.1136/bcr-2018-227356.

13. Van Steenbergen W and Vermylen J. Reversible hypoprothrombinemia in a patient with primary biliary cirrhosis treated with rifampicin. Am J Gastroenterol 1995; 90: 1526–1528. 1995/09/01.

81: Case report: Isolated gestational diabetes insipidus – rare and challenging to manage

Madeleine Cosgrave¹, Catherine Brumby^1,2, Lawrence P McMahon^1,2

1. Department of Renal Medicine, Box Hill Hospital, Eastern Health, Melbourne, VIC, Australia

2. Eastern Health Clinical School, Monash University, Melbourne, Vic, Australia

Introduction: Transient gestational diabetes insipidus (TDI) is a rare endocrine disorder complicating pregnancy. It is associated with significant maternal and neonatal morbidity. TDI frequently presents in relation to preeclampsia/HELLP syndrome and liver disease (including acute fatty liver of pregnancy), but can occur independently. TDI typically presents in third trimester and is characterised by increased clearance of maternal antidiuretic hormone (ADH) by excessive placental vasopressinase (also known as oxytocinase) activity. This is mediated through either placental overproduction from a large placental mass or reduced vasopressinase metabolism by the maternal liver. The condition usually self-resolves by 6 weeks postpartum. Clinical presentation varies, however severe maternal dehydration, hypernatraemia, oligohydramnios, and foetal compromise are frequent features.

Case report: A 29-year-old G2P1 previously healthy female presented with threatened pre-term labour at 32 ^+ 0 weeks gestation which was successfully treated with tocolysis and corticosteroids for fetal lung maturation. Fetal ultrasound demonstrated significant polyhydramnios and fetal macrosomia of unclear cause. She represented 24 h later with insatiable thirst and polyuria of >7L urine in 24 h. Her serum sodium was 137 mmol/L, creatinine 62 micromol/L, serum glucose 5.6 mmoL/L and serum osmolality 285 mmol/kg. Urine osmolality was low at 198 mmol/kg. There were no clinical features of preeclampsia or visual field defects, and she appeared adequately hydrated. Liver function tests, serum calcium, cortisol and thyroid tests were unremarkable. Isolated TDI was suspected and desmopressin was increased to 200 mcg twice daily until urine output was 4L/day. Confirmatory water deprivation testing was not performed due to risk of precipitating pre-term labour or fetal compromise. Weekly outpatient management included maternal clinical and biochemical assessment and fetal ultrasound scanning. Polyhydramnios partially resolved after initiation of desmopressin. At 37 ^+ 0 weeks’ gestation the patient developed pre-eclampsia and underwent emergency Caesarean section, delivering a large for gestational age baby (3.68 kg) with mild respiratory distress. Unfortunately, the placenta was not weighed. baby was monitored but did not have obvious polyuria. A postpartum pituitary MRI was unremarkable. Desmopressin was ceased by 2 months postpartum, coinciding with resolution of polyuria.

Discussion: Isolated TDI is associated with increased vasopressinase activity and large placental mass. In this case, an LGA birthweight supports a larger placental mass being contributory. Furthermore, may have triggered overexpression of placental vasopressinase/oxytocinase. Finally, corticosteroids have been demonstrated to antagonise ADH, possibly contributing to TDI risk. Interestingly, desmopressin is not thought to cross the placenta, so it remains unclear why polyhydramnios resolved soon after its commencement.