ISOM/NASOM 2022 Abstracts

Collaborating with Cardiac Services when Treating Parturients with Complex Cardiac Disease. Creating a Standard of Practice

Simon Apps¹, Parvesh Verma², Omaima Glesa³ and Kate Wiles⁴

¹Anaesthesia, The Royal London Hospital, London, United Kingdom

²Anaesthesia, The Royal London Hospital, London, United Kingdom

³Anaesthesia, The Royal London Hospital, London, United Kingdom

⁴Obstetric Medicine, The Royal London Hospital, London, United Kingdom

Abstract

Background and Purpose: Cardiac disease is the leading indirect cause of maternal death in the UK.(1) There is also an increasing number of parturients presenting with cardiovascular disease due to a combination of both increasing maternal age and more patients with congenital heart disease surviving to adulthood.(2) Maternal medicine centres in England are seeing patients with increasingly complex cardiac disease presenting to us for peripartum care. The aim of this study was to establish current practice in the UK regrading cardiac anaesthetist involvement in the care of pregnant patients with cardiovascular disease and generate consensus national guidance.

Methods: A questionnaire-based cohort study of maternal medicine centres in the UK collecting data on co-located cardiac anaesthetics and obstetrics, existing protocols for cardiac anaesthetist involvement in obstetric management and delivery planning. Data from these responses was used to create consensus UK guidance for the involvement of cardiac anaesthetists in the care of pregnant patients.

Results: Responses were received from 70% (7/10) of UK maternal medicine centres contacted. 100% of centres had no formal criteria for involvement with a cardiac anaesthetist, with discussions taking place on an as-required basis in all of centres. No maternal medicine centre had criteria for delivery in a cardiac centre, including transfer to a centre co-located with obstetrics, even though this does occur. Guidance based on cardiac disease severity including pulmonary hypertension and severe left ventricular dysfunction is proposed.

Conclusion: There are currently no guidelines on when a cardiac anaesthetist should be involved in the delivery of obstetric patients with cardiac disease. The proposed consensus guidance about involvement of a cardiac anaesthetist, for use across the maternal medicine centres, aims to improve standards and equity of care across the UK. A national map of co-located cardiac and obstetric units should be available to all maternal medicine centres.

References

1. MBRRACE-UK (2021). Saving Lives, Improving Mothers’ Care Maternal, Newborn and Infant Clinical Outcome Review Programme. [online] Available at: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf.

2. Vera Regitz-Zagrosek, Jolien W Roos-Hesselink ESC Scientific Document Group, 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy: The Task Force for the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC), European Heart Journal, Volume 39, Issue 34, 07 September 2018, Pages 3165–3241, https://doi.org/10.1093/eurheartj/ehy340

Impact of Pregnancy-Related Acute Kidney Injury on Maternal and Fetal Outcomes in High Dependency Unit Admissions in the United Kingdom

Hayley Martin^1,3, Katherine Clark¹, Kate Bramham², Bibi Niazi¹, Rehan Khan³, Nafiza Anwar³ and Kate Wiles³

¹Maternity Department, King’s College Hospital NHS Foundation Trust, London, England

²Nephrology Department, King’s College Hospital NHS Foundation Trust, London, England

³Maternity Department, The Royal London Hospital, Barts Health NHS Trust, London, England

Abstract

Background & Purpose: Pregnancy-related acute kidney injury (Pr-AKI) is associated with increased maternal morbidity¹ and mortality.² Pr-AKI affects 2.4% of pregnancies,³ and is a recognised complication of high-dependency care.⁴ The aim of this study was to examine risk factors for Pr-AKI and measure adverse pregnancy outcomes in peripartum admissions to high dependency units in UK.

Methods: A retrospective cohort analysis of admissions to two obstetric high dependency units from 2019-22. Pr-AKI was defined as a 1.5-fold increase in serum creatinine compared to a baseline within the preceding year.⁵ HDU admissions with Pr-AKI were compared to a matched group without Pr-AKI using T-tests, Chi-square and Mann-Whitney-U tests as appropriate for cohort size and distribution of data.

Results: The study included 20 women and birthing people with PR-AKI and 20 matched controls. Post-partum haemorrhage and severe hypertension were the most common reasons for HDU admission. There were no measurable demographic differences in women with Pr-AKI including ethnicity, diabetes and hypertension. Comparable volumes of intravenous fluid were administered in both groups (4375ml versus 3547ml; p=0.36). Women with Pr-AKI had more peripartum blood loss compared to those without (2072ml versus 1170ml; p=0.01). Pr-AKI was associated with longer hospital admission (5.23 days versus 4.0 days; p=0.04). There was no measurable difference in neonatal unit admission (15% versus 5%; p=0.62).

Conclusion: Pr-AKI is associated with higher volumes of blood loss and longer length of hospital stay. Pr-AKI is therefore likely to be an important factor in the peripartum experience of patients and healthcare cost. Larger, prospective data are needed to examine the role of haemorrhage management and volume replacement in reducing the burden of Pr-AKI.

References

1. Jim B, Garovic V. Acute Kidney Injury in Pregnancy. Seminars in Nephrology. 2017;37(4):378-385.

2. Liu Y, Ma X, Zheng J, Liu X, Yan T. Pregnancy outcomes in patients with acute kidney injury during pregnancy: a systematic review and meta-analysis. BMC Pregnancy and Childbirth. 2017;17(1).

3. Gama R, Clark K, Bhaduri M, Clery A, Wright K, Smith P et al. Acute kidney injury e-alerts in pregnancy: rates, recognition and recovery. Nephrology Dialysis Transplantation. 2020;36(6):1023-1030.

4. Silva Junior G, Saintrain S, Castelo G, Vasconcelos V, Oliveira J, Rocha A et al. Acute kidney injury in critically ill obstetric patients: a cross-sectional study in an intensive care unit in Northeast Brazil. Jornal Brasileiro de Nefrologia. 2017;39(4)

5. 1. NHS England Patient Safety Alert. Algorithm for detecting Acute Kidney Injury (AKI) based on serum creatinine changes with time. England.nhs.uk. 2014. Available from: https://www.england.nhs.uk/wp-content/uploads/2014/06/psa-aki-alg.pdf

Management of the Pregnant and Post-partum Patient on the Acute Medical Ward: A Retrospective Audit

Charline Bradshaw¹, Charlotte Cutler¹, James Sanderson¹ and Sophia Stone¹

¹St Richards Hospital, University Hospitals Sussex, Chichester, United Kingdom

Abstract

Background & Purpose, Methods, Results, Conclusion: Nair et al in 2016 described that 66% of the increased risk of maternal death in the UK could be attributed to medical comorbidities ¹. Additionally, two-thirds (65%) of the women who died in 2017-19 were known to have pre-existing medical problems as per the 2021 MBRRACE report² The published data highlighted the need for multi-disciplinary and patient centered care between Acute Medical, Midwifery, Maternal Medicine Specialists..With a particular focus on acute medical admission, we performed a two month retrospective audit examining the management of all pregnant patients admitted to the acute medical ward of our district general hospital. We included pregnant patients of all gestations and post partum (up to a year) in a randomly assigned two month period, who were admitted for care with an exacerbation of an existing medical condition or a new medical problem. We audited the time from admission to clinical review by a Medical Physician, time to review from an Obstetrician/Gynaecologist and whether liaison with the maternal medicine specialist was sought. We audited whether the patient had a named lead from both the medical and Obstetric/Gynaecology teams, whether the patient was managed clinically using a MEOWS³ chart, and whether there was a follow up plan made and if so, with whom⁴. We excluded pregnant or postpartum patients who attended via the medical ambulatory day unit unless they were admitted for inpatient management. Audited against local standards and recommendations made from the Royal College of Physicians Acute Care Toolkit⁴. 25 pregnant patients were admitted to the acute medical unit in our two month time period and 2 in the post partum period. The most common presenting complaint was shortness of breath. The majority of patient were seen and discussed with the Obstetric team on call and reviewed appropriately. We've highlighted a need for a more robust referral pathway post discharge into the maternal medicine service to ensure follow up.

References

1. Nair et al. 2016 Risk factors and newborn outcomes associated with maternal deaths in the UK from 2009 to 2013: a national case–control study

2. Mothers and babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK). Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-2019. MBRRACE-UK. www.npeu.ox.ac.uk/mbrrace-uk/rep

3. MEOWS is a scoring system specifically for pregnant women, similar to the NEWS2 score.

4. Acute care toolkit 15: Managing acute medical problems in pregnancy Nov 2019. Royal College of Physicians

National Time Trends in Preeclampsia and Gestational Diabetes in Denmark and Canada, 2005-2018 – A Path Towards Poorer Cardiometabolic Health?

W. Sia³, F. Lihme¹, A. Savu², S. Basit¹, R. Yeung³, O. Barrett⁴, L. Luoma²; D. Ngwezi², S. Davidge⁵, C. Norris⁶, M. Ospina⁷, C-L. Cooke⁵, R. Grenier⁸, J. Wohlfahrt¹, Mads Melbye⁹, J. Lykke¹⁰, P. Kaul^2,3 and H.A. Boyd¹

¹Department of Epidemiology Research, Statens Serum Institut, Denmark

²Canadian VIGOUR Center, University of Alberta, Edmonton, Canada

³Department of Medicine, University of Alberta, Edmonton, Canada

⁴Alberta Health Services, Alberta, Edmonton, Canada

⁵Departments of Obstetrics/Gynecology and Physiology, University of Alberta, Edmonton, Canada

⁶Faculty of Nursing, University of Alberta, Edmonton, Canada

⁷Department of Epidemiology and Public Health Sciences, Queen’s University, Edmonton, Canada

⁸Department of Computer Science, University of Alberta, Edmonton, Canada

⁹Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

¹⁰Department of Obstetrics and Gynecology, Rigshospitalet, Denmark

Abstract

Background & Purpose: Preeclampsia and gestational diabetes share similar risk factors and are both associated with later maternal chronic disease. Risk factor distributions have changed markedly over the last 20 years, but whether trends in the prevalence of preeclampsia and gestational diabetes have changed accordingly, is unclear.

Methods: Our register-based study used population-based cohorts from Denmark and the Canadian province of Alberta. Using linear binomial regression, we estimated time trends for preeclampsia and gestational diabetes based on all pregnancies resulting in live-born infants in the two cohorts in the period 2005-2018. We then investigated whether changing distributions of maternal age, parity, multiple pregnancy, comorbidity, and BMI over time could account for observed trends by adding these variables as covariates to the trend models.

Results: In cohorts including 846,130 (Denmark) and 688,316 (Alberta) pregnancies, the overall prevalence of preeclampsia increased from 2.4% and 1.7%, respectively, in 2005-2009 to 2.9% and 2.4%, respectively, in 2014-2018. The corresponding prevalence’s of gestational diabetes in the same periods were 2.2% and 4.6%, increasing to 3.9% and 8.3%. In both countries, the trends were statistically significant for both conditions (p<0.001 for all four trends). Changes in the joint distribution of maternal age, parity, and BMI accounted for most of the trend in preeclampsia, whereas changes in these variables could not entirely explain the marked increases in gestational diabetes over the study period.

Conclusion: The prevalence of both preeclampsia and gestational diabetes increased significantly in the period from 2005-2018, potentially increasing the burden of chronic disease among women in the coming decades.

References

No references.

Patient Perspectives on Lifestyle Intervention Programs After Hypertensive Disorders of Pregnancy: A Qualitative Study

Meghan Macphail¹, Judeah Negre², Kathleen Chaput^1,3, Sonia Butalia^1,2,4, Amy Metcalfe^1,2,3,4 and Kara Nerenberg^1,2,3,4

¹Department of Community Health Sciences, University of Calgary, Calgary, Canada

²Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta

³Department of Obstetrics and Gynecology, University of Calgary, Calgary, Canada

⁴Department of Medicine, University of Calgary, Calgary, Alberta

Abstract

Background: People who experienced a hypertensive disorder of pregnancy (HDP) have a 2-4 times increased risk of premature cardiovascular disease (CVD) compared to those without HDP¹ largely due to accumulation of CV risk factors (e.g., hypertension, dysglycemia, dyslipidemia, obesity) within the first five to ten years after delivery.² Many of these chronic diseases may be prevented through early health behaviour modifications.³ At present, postpartum health behaviour programs are limited by a lack of: 1) participant completion; 2) tailoring specifically for people post-HDP; 3) support for gender-related responsibilities unique to the postpartum period; and 4) mental health supports (including peer support) for health behaviours.^4,5,6

Purpose:

1. To evaluate patient-related determinants (i.e., demographic characteristics, social determinants of health, and patient-reported preferences) related to participation of post-HDP women in a health coaching program.

2. To examine patient-perspectives on a range of interventions (e.g., peer support, trained health coach, virtual sessions, etc.) to support health behaviours modifications (e.g., physical activity and nutrition) post-HDP.

Methods: This study integrates: 1) a cross-sectional patient questionnaire; and 2) semi-structured interviews of patient experiences and preferences for postpartum health behaviour programs. Interviews will be audio-recorded and transcribed. Results from both components will be integrated and triangulated in the analysis patient preferences using thematic analysis.

Results: This project in progress and results will be summarized and presented at the conference.

Conclusion: The information gained from this study on patient preferences is vital to inform the design and implementation of sex-specific and gender-transformative effective, evidence-based CVD prevention programs tailored for specifically for people after HDP.

References

1. Future risk of cardiovascular disease risk factors and events in women after a hypertensive disorder of pregnancy. Heart (British Cardiac Society). 2019;105(16):1273–1278. (Dutch). https://doi.org/10.1136/heartjnl-2018-313453

2. Trajectory of cardiovascular risk factors after hypertensive disorders of pregnancy: an argument for follow-up. Hypertension. 2019;(73):171-8. (Dutch).

3. Younger-Lewis D, McDonnell L, Westcott C, Elias N, Perron S, Martin N, et al. Effect of an intervention to improve the cardiovascular health of postpartum women with a history of hypertensive disorders of pregnancy. CJC. 2016;32(4), S9–S9. https://doi.org/10.1016/j.cjca.2016.02.025

4. Samayoa L, Grace SL, Gravely S, Scott LB, Marzolini S, Colella TJF. Sex differences in cardiac rehabilitation enrollment: a meta-analysis. Can J Cardiol. 2014;30(7):793-800. https://doi.org/10.1016/j.cjca.2013.11.007

5. Leger J, Letourneau N. New mothers and postpartum depression: a narrative review of peer support intervention studies. Health Soc Care Community. 2015;23(4): 337–348. https://doi.org/10.1111/hsc.12125

6. Patil SJ, Ruppar T, Koopman RJ, Lindbloom EJ, Elliott SG, Mehr DR, et al. Effect of peer support interventions on cardiovascular disease risk factors in adults with diabetes: a systematic review and meta-analysis. BMC Public Health. 2018;18(1):398–398. https://doi.org/10.1186/s12889-018-5326-8

A Case of Spontaneous Haemoperitoneum in Pregnancy

Stuart Quek¹, Amrita Viegas¹, Sumaya Islam¹, Saadia Waheed¹, Maria Mouyis¹

¹Luton and Dunstable University Hospital

Abstract

Background: Spontaneous Haemoperitoneum in Pregnancy (SHiP) is a rare surgical condition that can occur in pregnancy. The main aetiology of SHiP is unknown, but conditions such as endometriosis and controlled ovarian hyperstimulation have been identified as contributing factors (4,5,12). As well as other aetiologies such as splenic aneurysm rupture (3), rupture of utero-ovarian vessels (1) or uterine vessels (3), endometriosis, placenta percreta (7) and spontaneous rupture of unscarred uterus (8). The patient may present with an acute surgical abdomen, or dizziness, tachycardia, and hypotension. To the authors’ best knowledge, we present the sixth known case of idiopathic SHiP(8–11).

Case Presentation: A G1P0, 30-year-old patient, presented to the A&E department at 26 weeks gestation with acute epigastric pain, vomiting, dizziness and reported history of melena. On examination, she had tenderness and guarding in the abdomen, pallor, hypotension and tachycardia. A FAST scan was performed which demonstrated a large amount of free fluid in the abdomen. A significant drop in Hb to 3.0g/L was noted. A CT chest and MRI abdomen and pelvis showed an acute haematoma in the lesser sac, as well as moderate volume of free fluid within the abdomen and pelvis. No vascularity was seen on a bedside USS. A cardiotocography was done to assess fetal wellbeing and was normal. A diagnosis of SHiP was made. A joint diagnostic laparoscopic procedure under general anaesthesia with the general surgeons was performed. An oseophagoduodenoscopy (OGD) was also performed to identify possible cause of bleeding, given her previous oseophageal atraesia repair, fortunately it was normal. Following an uneventful recovery, the patient was discharged with both obstetric and surgical follow up. She subsequently had a normal labour and there were no complications in the postpartum period.

Conclusion: A greater awareness of SHiP in the medical and surgical specialities, as well as its associated risk factors, may help facilitate the diagnosis, encourage referral to the appropriate teams and expedite intervention, leading to improved maternal mortality and morbidity.

References

1. Sim Y, Kim J, Jeong Y, Rheu C, Chae H. Spontaneous hemoperitoneum in pregnancy (SHiP) complicated by endometriosis: A case report. Obstetrics and Gynecology Reports. 2020;4(2).

2. Pavlis T, Seretis C, Gourgiotis S, Aravosita P, Mystakelli C, Aloizos S. Spontaneous Rupture of Splenic Artery Aneurysm during the First Trimester of Pregnancy: Report of an Extremely Rare Case and Review of the Literature. Case Reports in Obstetrics and Gynecology. 2012;2012:1–3.

3. da Silva CM, Luz R, Almeida M, Pedro D, Paredes B, Branco R, et al. Hemoperitoneum during Pregnancy: A Rare Case of Spontaneous Rupture of the Uterine Artery. Case Reports in Obstetrics and Gynecology. 2020;2020.

4. Brosens IA, Fusi L, Brosens JJ. Endometriosis is a risk factor for spontaneous hemoperitoneum during pregnancy. Fertility and Sterility. 2009;92(4).

5. Brosens IA, Lier MC, Mijatovic V, Habiba M, Benagiano G. Severe spontaneous hemoperitoneum in pregnancy may be linked to in vitro fertilization in patients with endometriosis: a systematic review. Fertility and Sterility. 2016 Sep 1;106(3):692–703.

6. Roca LE, Hoffman MC, Gaitan LF, Burkett G. Placenta Percreta Masquerading as an Acute Abdomen. Obstetrics & Gynecology. 2009 Feb;113(2):512–4.

7. Nkwabong E, Kouam L, Takang W. Spontaneous uterine rupture during pregnancy: case report and review of literature. Afr J Reprod Health. 2007 Aug;11(2):107–12.

8. Kachmar S, Oujidi Y, Bouayed Z, Bkiyar H, Housni B. A case report of idiopathic spontaneous peritoneal and retroperitoneal hematoma of a pregnant woman. Annals of Medicine and Surgery. 2021 Nov;71:102954.

9. Koifman A, Weintraub AY, Segal D. Idiopathic spontaneous hemoperitoneum during pregnancy. Arch Gynecol Obstet. 2007 Sep;276(3):269–70.

10. Markou AG, Puchar A, Muray JM, Fysekidis M. Idiopathic spontaneous hemoperitoneum during pregnancy. Clin Exp Obstet Gynecol. 2017;44(1):162–5.

11. M. A. MN, I. R, H. H, H. S, R. R. Idiopathic spontaneous haemoperitoneum in pregnancy. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2017 Aug 28;6(9):4120.

12. Lier MCI, Malik RF, Ket JCF, Lambalk CB, Brosens IA, Mijatovic V. Spontaneous hemoperitoneum in pregnancy (SHiP) and endometriosis — A systematic review of the recent literature. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2017 Dec;219:57–65.

A Congenital Conundrum: Chondrodysplasia Punctata in Maternal Mixed Connective Tissue Disease

Elena Cravens¹, Srilakshmi Mitta² and Joanne Cunha³

¹Department of General Internal Medicine/Brown University/Providence, RI, USA

²Department of Obstetric Medicine/Brown University/Providence, RI, USA

³Department of Rheumatology/Brown University/Providence, RI, USA

Abstract

Background: Chondrodysplasia punctata (CP) is a heterogeneous condition caused by single gene disorders, teratogenic exposures and recently has been associated with maternal autoimmune diseases. It is characterized by abnormal development of bone and cartilage. Most common findings include mid-face hypoplasia and nasal depression. Here we describe a case where maternal autoimmune disease was the suspected pathogenesis of a fetus with chondrodysplasia punctata.

Case Presentation: Our patient is a 32-year-old woman G2P101 with past medical history of mixed-connective tissue disease (MCTD) with features of Raynaud’s phenomenon, interstitial lung disease, sclerodactyly and inflammatory arthritis with positive ANA 1:10240, dsDNA, SSA, SSB, Smith and RNP managed with hydroxychloroquine, who presented for a perinatal visit to the combined Obstetric Medicine-Rheumatology clinic. During her first pregnancy, she delivered a child with CP at 32 weeks’ gestation due to pre-eclampsia. Her child was diagnosed with CP clinically with a skeletal survey after being found to have midface hypoplasia. Genetic screening was done with whole exome sequencing including mitochondrial DNA which found no pathologic variants linked to CP. In her current pregnancy, she was managed by maternal-fetal medicine, rheumatology and obstetric medicine. She was continued on hydroxychloroquine. At 18 weeks’ gestation her anatomic survey demonstrated micrognathia, midface hypoplasia, flat nasal bridge, sacral appendage and polyhydramnios. At 31 weeks’ gestation during fetal monitoring ultrasound, she was diagnosed with stillbirth and had an induced uncomplicated vaginal delivery. Fetal autopsy demonstrated stippling of calcanei consistent with CP. Her post-partum course was complicated by a flare of her MCTD which was treated with azathioprine and a prednisone taper.

Conclusion: Chondrodysplasia punctata has been associated with maternal autoimmune disease specifically SLE and MCTD specifically in women with high RNP titers. This case illustrates the link between MCTD and offspring with CP, highlighting the importance of autoimmune disease control prior to conception.

References

1. Tardif ML, Mahone M. Mixed connective tissue disease in pregnancy: A case series and systematic literature review. Obstet Med. 2019;12(1):31-37. doi:10.1177/1753495X18793484

2. Pandita A, Panghal A, Gupta G, Singh V. Neonatal punctate calcifications associated with maternal mixed connective tissue disorder (MCTD). BMJ Case Rep. 2018;2018:bcr2017223373. Published 2018 Oct 12. doi:10.1136/bcr-2017-223373

3. Schulz SW, Bober M, Johnson C, Braverman N, Jimenez SA. Maternal mixed connective tissue disease and offspring with chondrodysplasia punctata. Semin Arthritis Rheum. 2010;39(5):410-416. doi:10.1016/j.semarthrit.2008.10.003

4. Spranger JW. Metaphyseal chondrodysplasia. Postgrad Med J. 1977;53(622):480-487. doi:10.1136/pgmj.53.622.480

5. Vinet E, Pineau CA, Clarke AE, et al. Major congenital anomalies in children born to women with systemic lupus erythematosus. Arthritis Res Ther. 2012;14(Suppl 3):A11. doi:10.1186/ar3945

Blinding Lights: Acute Persistent Vision Loss in Pregnancy

Marie Leung¹, Ilia Ostrovski², Melin Peng-Franklin³, Ahraaz Wyne²

¹Division of General Internal Medicine, Queen's University, Kingston, Ontario, Canada

²Department of Medicine, McMaster University, Hamilton, Ontario, Canada

³Department of Obstetrics & Gynecology, McMaster University, Hamilton, Ontario, Canada

Abstract

Background & Purpose: Acute persistent vision loss in pregnancy is an emergent presentation with a broad differential and should prompt rapid assessment and treatment of the underlying etiology. In pregnancy, causes can include: preeclampsia, severe gestational hypertension and HELLP syndrome. Non-obstetrically related etiologies that can exacerbate in pregnancy include: optic neuritis, giant cell arteritis, central retinal artery occlusion or retinal detachment.

Case Presentation: In this case report, we describe a case of acute vision loss due to Purtscher’s-like retinopathy, a rare but serious complication of pancreatitis in pregnancy.

A 39-year-old multiparous Caucasian woman with an intrauterine pregnancy at 20+5 weeks gestation sought medical attention after a one week history of nausea, vomiting, abdominal pain and significant alcohol intake. She was admitted for acute pancreatitis, secondary to the alcohol use and hypercalcemia due to calcium-alkali syndrome from excessive calcium carbonate (Tums^TM) intake. During her admission, she developed sudden, progressive bilateral vision loss. Her visual acuity was diminished, with worsened symptoms in the left eye compared to her right eye. Ophthalmologic examination revealed retinal whitening (consistent with “Purtscher flecken") and dot hemorrhages. She was ultimately diagnosed with Purtscher’s-like retinopathy.

Conclusion: Purtscher’s-like retinopathy is a rare but serious condition that can lead to permanent vision loss. Although typically associated with trauma, Purtscher’s-like retinopathy is also associated with pancreatitis, thrombotic thrombocytopenic purpura, associated with pre-eclampsia or post labour and delivery. Management is usually conservative, with 50% of cases demonstrating modest vision recovery by 6 months. Treatment can involve systemic corticosteroids however evidence remains limited.

To our knowledge, this is the first published case of Purtscher’s-like retinopathy in pregnancy unrelated to pre-eclampsia. Given the impact of permanent visual loss associated with Purtscher’s-like retinopathy, more research is needed to determine treatments to substantively improve outcomes.

References

No references

Case of Severe Metabolic Acidosis from Chronic Acetaminophen use in Pregnancy

Katherine Steckham¹, Lonnie Pyne¹, Julian Owen¹ and Serena Gundy¹

¹Department of Medicine, McMaster University, Hamilton, Canada

Abstract

Background & Purpose: Accumulation of 5-oxoproline, an intermediate in the gamma-glutamyl cycle, is an uncommon cause of metabolic acidosis. Acetaminophen use in combination with predisposing risk factors such as malnutrition, sepsis, pregnancy, liver disease and renal impairment depletes glutathione stores and can lead to 5-oxoprolinemia. Clinical manifestations include altered mental status, metabolic acidosis and hyperventilation.

Methods: A 29-year-old G1 at 37 weeks gestation presented with a two-day history of dyspnea. Her medical history included chronic back pain due to degenerative disc disease. She was taking OxyNEO, Oxycodone, Extra Strength Acetaminophen and Gabapentin for pain management.

Results: She was tachycardic and tachypneic with normal oxygen saturations and had pitting edema to the knees. Venous blood gas revealed pH 7.03, partial pressure of carbon dioxide 17 mmHg and bicarbonate 3 mmol/L. The albumin corrected anion gap was high at 19 mmol/L and there was a concurrent non-anion gap metabolic acidosis. Common etiologies were ruled out (normal lactate, negative toxic alcohols, negative salicylates, normal urea, normal glucose, slightly increased beta-hydroxybutyrate). Venous thromboembolism was also excluded and NT-proBNP was normal. Creatinine was elevated at 70 umol/L (previously 47 umol/L) and the initial acetaminophen level was 77 umol/L (therapeutic range). Calculated urine anion gap was positive. Acetaminophen was held and she was started on a bicarbonate infusion with resolution of her metabolic acidosis. She subsequently underwent Caesarean section for non-reassuring fetal heart rate and abnormal biophysical profile. Urine returned positive for organic acids consistent with a diagnosis of 5-oxoprolinemia from significant acetaminophen use (estimated 9-12 g/day).

Conclusion: Venous blood gas is an important test when evaluating dyspnea in pregnancy. 5-oxoprolinemia should be considered in the setting of unexplained metabolic acidosis and acetaminophen use. Acetaminophen remains safe to utilize during pregnancy, however the recommended maximum daily dose should be reviewed with patients during routine antepartum visits.

References

No references.

First Presentation of ANCA Positive Vasculitis in Pregnancy

Swati Bhagwat¹, A Sofia Cerdeira^2,3, Farhan Javaid⁴, Ruth Curry², Charlotte Frise^2,5

¹Obstetrics and Gynaecology,Wexham Park Hospital,Frimley NHS Foundation Trust, Slough,UK

²Obstetrics and Gynaecology,Oxford University Hospitals NHS Foundation Trust, Oxford, UK

³Obstetrics and Gynaecology,University of Oxford, Oxford,UK

⁴Rheumatology,University Hospitals of Leicester NHS Trust,Leicester,UK

⁵Obstetric Medicine,Imperial College Healthcare NHS Trust, London, UK

Abstract

Background: Antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis presenting for the first time in pregnancy is very rare, but awareness is important as it can cause significant maternal and fetal morbidity and is potentially life-threatening if not recognised or under-treated.

Method and Results: We describe a 19-year-old woman who developed ANCA-associated vasculitis in the second trimester of her first pregnancy. She initially presented with a petechial rash and cough at 25 weeks’ gestation, and then developed breathlessness. Significant pulmonary haemorrhage was shown on Cross Sectional imaging of the chest, with a corresponding reduction in haemoglobin. She rapidly improved with prednisolone, cyclophosphamide and plasma exchange. SARS-CoV-2 infection identified on routine screening further complicated the management. At 34 weeks’ gestation she experienced a flare, with the possibility of superimposed pre-eclampsia (increase in liver enzymes, creatinine and sFlt/PlGF ratio). After multidisciplinary team discussion she underwent a caesarean section. Postnatally she continued cyclophosphamide and started azathioprine.

Conclusion: ANCA-associated vasculitis can result in life-threatening complications. The initial features can be non-specific, so a high index of suspicion is required, particularly in women with multisystem abnormalities. Close monitoring for potential complications is advised as urgent imaging may be needed. Aggressive immunosuppressive treatment is recommended as steroids alone are usually insufficient.

Cyclophosphamide can be used in later pregnancy and can result in a dramatic improvement, as was seen here. If delivery needs to be expedited, mode of birth (i.e. caesarean delivery vs vaginal birth) is dictated by the obstetric picture, with caesarean delivery being indicated for the usual obstetric reasons.

References

1. Hussein A, Al Khalil K, Bawazir Y M (August 10, 2020) Anti-Neutrophilic Cytoplasmic Antibody (ANCA) Vasculitis Presented as Pulmonary Hemorrhage in a Positive COVID-19 Patient: A Case Report. Cureus 12(8): e9643. doi:10.7759/cureus.9643

2. Lenka B, Zdenka H, Eva H. Pathophysiology of ANCA-associated vasculitis. Cesk Patol. 2020 Spring;56(2):65-67. English. PMID: 32493021.

3. Daher A, Sauvetre G, Girszyn N, Verspyck E, Levesque H, Le Besnerais M. Granulomatosis with polyangiitis and pregnancy: A case report and review of the literature. Obstet Med. 2020 Jun;13(2):76-82. doi: 10.1177/1753495X18822581. Epub 2019 Mar 16. PMID: 32714439; PMCID: PMC7359661.

4. Pefanis A, Williams DS, Skrzypek H, Fung A, Paizis K. A case of ANCA-associated vasculitis presenting de novo in pregnancy, successfully treated with rituximab. Obstet Med. 2020 Mar;13(1):41-44. doi: 10.1177/1753495X18780853. Epub 2018 Jul 26. PMID: 32284732; PMCID: PMC7133104.

How to Respond to DKA in Pregnancy - From the Two Contrasting Experienced Cases

Hironobu Hyodo¹, Miki Shibakawa¹, Miho Hatanaka¹, Kanami Iwasa¹, Chikako Hikosaka¹, Shinya Imada¹ and Koji Kugu¹

¹Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan

Abstract

Background: Diabetic ketoacidosis (DKA) in pregnancy is rare but may have very serious consequences for the mother and the fetus(es). There have been no common strategies for DKA in pregnancy due to its rarity.

Purpose: To discuss how we should respond to DKA in pregnancy.

Methods: Review the two contrasting cases we have experienced.

Results: Case 1: 31y.o., G2P0. No diabetes and serum or urine glucose had been normal during the first and the second trimesters. She had become feeling thirsty from the 32^nd week, the urine test was 4+ at the 32^nd and 34^th weeks. Fasting blood glucose was 203 in the 35^th week and was referred to us in the 36^th week. The fetal condition was reassuring on the referral, then she was treated with insulin and delivered a healthy baby of 2,832 g in the 39^th week.

Case 2: 31y.o., G1P0. No diabetes and serum or urine glucose had been normal by the 26^th week. The urine test was 4+ at the 26^th week. After that, she suffered from dyspnea and was taken to a nearby hospital for an emergency. Fetal bradycardia of about 80 to 100 bpm was confirmed and then retransferred to us promptly. And then blood sugar was revealed 516. Normal saline and insulin were administrated. Fetal heart rate was back to 120 but severe late deceleration was seen repeatedly. Immediate cesarean section was executed but the baby of 1,224g was in asphyxia and had ischemic encephalopathy.

Conclusion: DKA in pregnancy is an emergency for the mother. Thus, the treatment for the mother should be initiated immediately. As long as the fetal condition would be reassuring, you can focus on treating the mother. If the fetal condition would be non-reassuring, you should execute prompt termination at least after starting saline and insulin.

References

No references.

Hypercalcemia of Unknown Etiology in Pregnancy, A Case Report

Ellen Miles¹ and Tessa Chaworth-Musters¹

¹Division of Internal Medicine, BC Women's Hospital, University of British Columbia, Vancouver, Canada

Abstract

Background & Purpose, Methods, Results, Conclusion: Hypercalcemia is a rare metabolic complication of pregnancy that can affect both maternal and fetal outcomes, and may lead to increased rates of pre-eclampsia, preterm delivery, and potentially neonatal tetany and seizures. The most common cause of hypercalcemia in pregnancy is primary hyperparathyroidism, however other rare causes must be excluded, and require investigation in pregnancy. Here we present a case of hypercalcemia in pregnancy of unknown etiology, presenting with low PTH, anemia, and impaired renal function, whose diagnostic work-up is ongoing.41 year-old G₂P₁ referred for anemia, refractory to IV iron in the first trimester. Chart review revealed hypercalcemia with a serum calcium of 3.08 mmol/L, impaired renal function, a history of paraesthesias, nephrolithiasis and mood disturbance. Patient presented with symptoms of nausea, vomiting and abdominal pain. Previous pregnancy was significant for anemia, that recovered between pregnancies, and preterm delivery in the setting of cervical incompetence. Family history is significant for a sister with impaired renal function and hypercalcemia.Physical exam was unremarkable, she remains normotensive.Initial work-up demonstrated an undetectable PTH, and inappropriately normal 24 hr urine calcium and 25-hydroxyvitamin D. Anemia work-up was negative for monoclonal protein, hemolysis, and nutritional deficiencies. Screening for malignancy with MRI was negative. She is currently being managed with intermittent IV fluids, furosemide, and calcitonin with improvement in her symptoms.Given her suspected chronic presentation of hypercalcemia and family history, a genetic syndrome is high on our differential at this time. However, humoral hypercalcemia of malignancy, PTHrp-related hypercalcemia of pregnancy, and abnormal vitamin D metabolism have not yet been excluded. Screening for genetic syndromes associated with nephrolithiasis has been completed by Adult Metabolics. Pregnancy and delivery outcomes will be reported as they become available.

References

1. Dandurand, Karl; Ali, Dalal; Khan, Aliya. Hypercalcemia in Pregnancy. Endocrinol Metab Clin N Am 2021; 50: 753-768

2. Appelman-Dijkstra, Natasha M; Ertl, Diana-Alexamdra; Zillikens, MC; Rjenmark, Lars; Winter, Elizabeth M. Hypercalcemia during pregnancy: management and outcomes for mother and child. Endocrine 2021; 71(3): 604-610

Pregnancy in Women with Extreme Short Stature and Low Body Weight

Joseph O'Sullivan¹, Hifsa Mahmood¹ and Charlotte Frise¹

¹Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom

Abstract

Background & Purpose: Women of extreme short stature and low body weight are likely to be at particular risk of medical complications in pregnancy.

Methods: In the context of caring for a patient with Bethlem Myopathy, who was 130cm tall (body mass index 12 kg/m²), we reviewed the literature on pregnancy in women with extreme short stature. Here we describe her case and relevant literature.

Results: Several conditions associated with extreme short stature are also associated with subfertility, however this should not be assumed, and contraception should always be discussed. Pregnancy risks in some conditions associated with short stature (e.g. achondroplastic dwarfism) have been described, and include increased rate of caesarean section and preterm birth, alongside maternal cardiac and respiratory complications. Our literature review and clinical experience indicate that such complications may be more common in all women of extreme short stature (independent of underlying condition). Planning for management of blood loss at delivery and the dosing of obstetric medications is also an important aspect which we will discuss in more detail.

Conclusion: This case illustrates many complications that occur in women of short stature, and the particular importance of medication dosing. Pregnancy in this cohort is high risk, and therefore appropriate pregnancy planning and counselling with these risks in mind is essential.

References

No references.

Repeat Doses of Sotrovimab for Recurrence of COVID-19 in a High-Risk Pregnancy

Antonio De Marvao¹, Siara Teelucksingh¹, Jennifer Spillane^2,3, Anna Goodman⁴, Catherine Nelson-Piercy¹, Surabhi Nanda⁵ and Anita Banerjee¹

¹Department of Obstetric Medicine, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.

²Department of Neurology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

³National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen Square, London, United Kingdom

⁴Department of Infection, St Thomas Hospital, Guy's and St Thomas NHS Foundation Trust, London, United Kingdom

⁵Department of Obstetrics, Maternal Fetal Medicine, Guy's and St Thomas NHS Foundation Trust, London, United Kingdom

Abstract

Background: Myasthenia gravis (MG) is an autoimmune disorder leading to variable degrees of skeletal muscle weakness. During pregnancy, infections can trigger exacerbations and should be treated promptly and aggressively.⁽¹⁾

 Sotrovimab is a monoclonal antibody used as monotherapy in high-risk, symptomatic non-hospitalized patients at risk of developing COVID-19 disease. ⁽²⁾ It is thought to have retained activity against SARS-CoV-2 omicron variant. ⁽³⁾ Limited data are available on its use in pregnancy.

Case: A 39-year-old woman with severe generalized MG, was referred to our joint neuro-obstetric multidisciplinary service. Her two previous pregnancies were complicated by severe exacerbations of MG necessitating intensive care admissions, and preterm labour. Her long-term therapy included high dose steroids, intravenous immune globulin (IVIG) and plasma exchanges. In this pregnancy, she additionally received rituximab in the first-trimester, allowing her prednisolone to be weaned to 20 mg daily, with ongoing 3-weekly IVIG. She received 3 doses of the Pfizer COVID-19 vaccine.

At 19 weeks she developed mild coryzal symptoms, sore throat and myalgia. Lateral flow and polymerase chain reaction tests in the community confirmed infection with SARS-CoV-2. She was treated with sotrovimab with uneventful recovery at home.

 At 31 weeks, she again tested positive for SARS-CoV-2, after reporting mild COVID-19 symptoms. She received a second dose of sotrovimab and had a quick recovery. Subsequent SARS-CoV-2 genotyping indicated she had contracted the Omicron-BA.2 variant.

 Fetal surveillance for growth (SARS-CoV-2) and arthrogryposis (MG) did not raise concerns. At 35⁺³ weeks, she went into spontaneous labour and was delivered by caesarean section for evolving chorioamnionitis, with uneventful recovery for mother and baby.

Discussion: We report a case of repeated treatment with sotrovimab (in second and third trimesters) of a high-risk, non-hospitalized pregnant woman, who was re-infected with SARS-CoV-2. We identified no immediate maternal, fetal or neonatal complications following two doses of sotrovimab for mild COVID-19.

References

1. Norwood F, Dhanjal M, Hill M, James N, Jungbluth H, Kyle P, O'Sullivan G, Palace J, Robb S, Williamson C, Hilton-Jones D, Nelson-Piercy C. Myasthenia in pregnancy: best practice guidelines from a U.K. multispecialty working group. J Neurol Neurosurg Psychiatry. 2014;85(5):538.

2. Gupta A, Gonzalez-Rojas Y, Juarez E, Crespo Casal M, Moya J, Rodrigues Falci D, Sarkis E, Solis J, Zheng H, Scott N, Cathcart AL, Parra S, Sager JE, Austin D, Peppercorn A, Alexander E, Yeh WW, Brinson C, Aldinger M, Shapiro AE. Effect of Sotrovimab on Hospitalization or Death Among High-risk Patients With Mild to Moderate COVID-19: A Randomized Clinical Trial. Jama. 2022;327(13):1236.

3. Cameroni E, Bowen JE, Rosen LE, Saliba C, Zepeda SK, Culap K, Pinto D, VanBlargan LA, De Marco A, di Iulio J, Zatta F, Kaiser H, Noack J, Farhat N, Czudnochowski N, Havenar-Daughton C, Sprouse KR, Dillen JR, Powell AE, Chen A, Maher C, Yin L, Sun D, Soriaga L, Bassi J, Silacci-Fregni C, Gustafsson C, Franko NM, Logue J, Iqbal NT, Mazzitelli I, Geffner J, Grifantini R, Chu H, Gori A, Riva A, Giannini O, Ceschi A, Ferrari P, Cippà PE, Franzetti-Pellanda A, Garzoni C, Halfmann PJ, Kawaoka Y, Hebner C, Purcell LA, Piccoli L, Pizzuto MS, Walls AC, Diamond MS, Telenti A, Virgin HW, Lanzavecchia A, Snell G, Veesler D, Corti D. Broadly neutralizing antibodies overcome SARS-CoV-2 Omicron antigenic shift. Nature. 2022;602(7898):664.

Rhomboencephalitis: A Rare but Potentially Fatal Cause of Headache in Pregnancy

Siara Teelucksingh¹, Antonio de Marvao¹, Renuka Murali Govind, Catherine Nelson-Piercy¹, Oseme Etomi¹, Aisling Brown², Guy Leschziner³ and Anita Banerjee¹

¹Department of Obstetric Medicine, St. Thomas’ Hospital, Guy's and St. Thomas’ NHS Foundation Trust, London, United Kingdom

²Department of Infectious Diseases, St. Thomas’ Hospital, Guy's and St. Thomas’ NHS Foundation Trust, London, United Kingdom

³Department of Neurology, St. Thomas’ Hospital, Guy's and St. Thomas’ NHS Foundation Trust, London, United Kingdom

Abstract

Background: Rhomboencephalitis is a rare but potentially fatal neuroinflammatory condition that can lead to progressive brainstem dysfunction.¹ Rhomboencephalitis is a differential diagnosis of headache in pregnancy, particularly as early presentations can be non-specific.²

Case: A 31-year-old presented at 29+5 weeks gestation with five days of nausea and fever, followed by subacute onset of occipital headache, altered cognition, drowsiness and unsteady gait. Initial normal investigations reassured clinicians and she was repeatedly discharged until representing for the fourth time in five days.

 On examination, she had a low-grade pyrexia, appeared drowsy, had difficulty articulating words, bilateral intention tremor and broad-based ataxic gait. Magnetic resonance imaging of the brain revealed subtle brainstem hyperintensities affecting the dorsal brainstem and bilateral cerebellar hemispheres. Lumbar puncture demonstrated a raised opening pressure of 20.3 cmH2O. Cerebrospinal fluid (CSF) revealed pleocytosis with WBC count 272 (100% lymphocytes), elevated protein 0.86, glucose 2.7 mmol/L (plasma glucose 4.4). CSF and blood microbiological stains, viral PCR, cultures, molecular analyses, CSF 16s bacterial rDNA, NMDA and aquaporin antibodies were all negative. Throat swab was positive for enterovirus/rhinovirus.

 Empiric antimicrobial therapy was given (aciclovir, amoxicillin and ceftriaxone) until CSF and blood microbiological analysis excluded infective aetiologies, including listeriosis. A diagnosis of parainfective rhomboencephalitis was made.

 Her headache improved within one day; speech, coordination and cognitive function improved daily. An electroencephalogram on day 8 showed no features of encephalitis. She had full clinical recovery by day 14.

Discussion: Rhomboencephalitis is associated with significant morbidity and mortality and a high index of suspicion must be maintained for prompt investigation and empirical antimicrobial treatment.³ The most common infectious pathogens are listeria, enterovirus and herpes simplex but parainfective, autoimmune and paraneoplastic aetiologies must also be considered.⁴ Multiple attendances should always raise suspicion for a pathological process.

References

1. Michael, L. Madison; Mazumder, Shirin A; Gelfand, Michael S. Differential Diagnosis of a Patient With Rhomboencephalitis. Infectious Diseases in Clinical Practice: March 2011 - Volume 19 - Issue 2 - p 134-136 doi: 10.1097/IPC.0b013e3181f47394

2. Sonu SK, Lai YW, Verma K, Sitoh YY, Purohit B. Enterovirus-related rhombencephalitis and myelitis in the third trimester of pregnancy: A case report highlighting clinico-radiological findings at diagnosis and follow-up. Radiol Case Rep. 2020 Jun 23;15(8):1323-1330. doi: 10.1016/j.radcr.2020.05.062. PMID: 32612733; PMCID: PMC7322137.

3. Cleaver J, James R, Rice CM. Rhomboencephalitis. Practical Neurology 2021;21:108-118.

4. Campos LG, Trindade RA, Faistauer Â, Pérez JA, Vedolin LM, Duarte JÁ. Rhombencephalitis: pictorial essay. Radiol Bras. 2016;49(5):329-336. doi:10.1590/0100-3984.2015.0189

Successful Management of Idiopathic Granulomatous Mastitis in Pregnancy and Lactation with Prednisone and Azathioprine

Stephanie G. Braunthal^1,2, Elena N. Cravens^2,3, Erica J. Hardy^1,2 and Kenneth K. Chen^1,2

¹Department of Medicine, Women and Infants Hospital, Providence, Rhode Island, United States of America

²Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America

³Department of General Internal Medicine, Rhode Island Hospital, Providence, Rhode Island, United States of America

Abstract

Background & Purpose: Idiopathic granulomatous mastitis is a rare, often chronic, benign disease of the breast that affects women of reproductive age, the etiology of which is not fully understood. No standard treatment guidelines exist. Reported medical strategies in pregnancy include glucocorticoids, drainage, and observation, but have not yet included disease-modifying antirheumatic drugs.

Case: A 27 year-old G2P1001 with a recent history of a benign breast mass presented at 23 weeks gestation with progressive pain and swelling of the right breast. Ultrasound revealed a 6.6 x 5.0 x 2.9 cm heterogeneous hypoechoic mass. 32 cc of purulent fluid were aspirated, sent for culture, and the patient received dicloxacillin. The collection reaccumulated within three days, resulting in hospital admission for drainage and intravenous ampicillin-sulbactam. Cultures grew Corynebacterium minutissimum. Surgical pathology from subsequent core needle biopsy revealed granulation tissue, acute and chronic inflammation, noncaseating granulomas, and giant cells, with negative gram stain, AFB, and PAS, consistent with cystic neutrophilic granulomatous mastitis. Six months prior, biopsy of a smaller mass, that had resolved by early pregnancy, was negative for carcinoma and microorganisms, but contained neutrophils, chronic inflammatory cells, and giant cells with associated wispy acellular eosinophilic material. Prednisone 10 mg daily and azathioprine 50 mg daily were started at 25 weeks gestation, which controlled symptoms through planned Cesarean delivery at 39 weeks gestation. No obstetric or neonatal complications occurred, including hyperglycemia. The mastitis flared on postpartum day two, impeding milk expression, and resolved after an increase to prednisone 15 mg daily and azathioprine 100 mg daily. The infant preferred latching to the unaffected breast, and the patient pumps the affected breast.

Conclusion: We describe a pregnant patient diagnosed with idiopathic granulomatous mastitis who was successfully treated in pregnancy through lactation with prednisone and azathioprine.

References

No references.

Acute Fatty Liver in Pregnancy Presenting in the Second Trimester: A Systematic Review

Laurence Bourque¹ and Michèle Mahone^2,3

¹Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada

²Internal medicine and obstetric medicine, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada

³Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada

Abstract

Objective: Acute fatty liver of pregnancy (AFLP) is a rare pathology typically occurring during the third trimester.^1,2 There are few published cases of second trimester AFLP. We present the clinical features, evolution, and outcomes of these cases.

Data Sources: A systematic search was performed for publications from 1946 to August 2021 in MEDLINE, Embase, EBM Reviews, and CINAHL Complete.

Methods: The study population included pregnant women with clinical diagnosis of AFLP or a biopsy compatible with AFLP in the second trimester. We included data from retrospective cohort studies (1), case series (3) and case reports (10).

Results: Fourteen articles describing 14 women diagnosed with AFLP in the second trimester were found from 6 587 articles screened.

 Mean maternal age was 28.7 years old and the diagnosis was made between 20 and 27.7 weeks of gestational age. All pregnancies were singleton and 50% of the cases were primiparous. Thirteen of the 14 cases had 7 or more Swansea Criteria at diagnosis.^3,4,5 The most frequent symptoms were vomiting (86%) and abdominal pain (71%). Elevated bilirubin (92%), abnormal liver enzymes (100%), and coagulopathy (90%) were the most frequent paraclinical findings. Ten cases had a liver biopsy showing microvesicular steatosis. Blood transfusion requirement, acute renal failure, hypoglycemia, and encephalopathy were the most common maternal complications. There were 3 cesarean deliveries, 4 spontaneous vaginal deliveries and 3 induced vaginal deliveries. Seven deliveries were on the day of diagnosis, 4 within the following 4 weeks, and 3 within 3 months. No maternal deaths occurred, but 7 fetal deaths and 3 neonatal deaths were reported.

Conclusion: AFLP diagnosed in the second trimester is a rare condition with few published cases. Neonatal mortality and maternal morbidity are high, but no maternal mortality was reported. Most cases had nonspecific symptoms and paraclinical findings, but a majority had compatible biopsies.

References

1. Castro, M. A., Fassett, M. J., Reynolds, T. B., Shaw, K. J., & Goodwin, T. M. (1999). Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. American journal of obstetrics and gynecology, 181(2), 389-395.

2. Knight, M., Nelson-Piercy, C., Kurinczuk, J. J., Spark, P., Brocklehurst, P., & System, U. K. O. S. (2008). A prospective national study of acute fatty liver of pregnancy in the UK. Gut, 57(7), 951-956.

3. Nelson, D. B., Yost, N. P., & Cunningham, F. G. (2013). Acute fatty liver of pregnancy: clinical outcomes and expected duration of recovery. American Journal of Obstetrics & Gynecology, 209(5), 456.e451-457.

4. Goel, A., Ramakrishna, B., Zachariah, U., Ramachandran, J., Eapen, C. E., Kurian, G., & Chandy, G. (2011). How accurate are the Swansea criteria to diagnose acute fatty liver of pregnancy in predicting hepatic microvesicular steatosis? Gut, 60(1), 138-140.

5. Minakami, H., Morikawa, M., Yamada, T., Yamada, T., Akaishi, R., & Nishida, R. (2014). Differentiation of acute fatty liver of pregnancy from syndrome of hemolysis, elevated liver enzymes and low platelet counts. Journal of Obstetrics & Gynaecology Research, 40(3), 641-649.

6. de Oliveira, C. V., Moreira, A., Baima, J. P., Franzoni, L. d. C., Lima, T. B., Yamashiro, F. d. S., Coelho, K. Y. R., Sassaki, L. Y., Caramori, C. A., Romeiro, F. G., & Silva, G. F. (2014). Acute fatty liver of pregnancy associated with severe acute pancreatitis: A case report. World journal of hepatology, 6(7), 527-531.

7. Hartwell, L., & Ma, T. (2014). Acute fatty liver of pregnancy treated with plasma exchange. Digestive Diseases & Sciences, 59(9), 2076-2080.

8. Yassin, A., Denguezli, W., Fessi, A., Njim, L., Falah, R., Zakhama, A., & Sakouhi, M. (2011). Mild clinical presentation of acute Fatty liver in the second trimester of pregnancy. Case reports in obstetrics and gynecology, 2011, 402710.

9. Jwayyed, S. M., Blanda, M., & Kubina, M. (1999). Acute fatty liver of pregnancy. The Journal of emergency medicine, 17(4), 673-677.

10. Modir, J. G., Kuczkowski, K. M., & Moeller-Bertram, T. (2008). Peripartum care of the parturient with acute fatty liver of pregnancy. Acta anaesthesiologica Belgica, 59(1), 51-53.

11. Onwuagbu, O. U., Mnyani, C. N., Ntshwanti, N., & Wadee, R. (2018). An atypical presentation of acute fatty liver of pregnancy. South African Journal of Obstetrics and Gynaecology, 24(2), 40-42.

12. Fujimura, N., Omote, T., Inagaki, N., Arakawa, J., Kotaki, M., & Namiki, A. (1998). Anesthetic management of a patient with acute fatty liver of pregnancy. Journal of anesthesia, 12(3), 160-163.

13. Wong, M., Hills, F., Vogler, K., Zardawi, I., & Nandi, N. (2020). Acute Fatty Liver of Pregnancy From 18 Weeks' Gestation. Hepatology (Baltimore, Md.), 71(6), 2167-2169.

14. Suzuki, S., Watanabe, S., & Araki, T. (2001). Acute fatty liver of pregnancy at 23 weeks of gestation. BJOG : an international journal of obstetrics and gynaecology, 108(2), 223-224.

15. Ramadan, M. K., Khaza'al, J., Cha'ar, D., Bazzi, Z., Bachnak, R., & Haibeh, P. (2021). Second-trimester acute fatty liver disease of pregnancy: A brief review of the literature and a case report. Journal of Obstetrics & Gynaecology Research, 47(1), 34-43.

16. Burroughs, A. K., Seong, N. H., Dojcinov, D. M., Scheuer, P. J., & Sherlock, S. V. (1982). Idiopathic acute fatty liver of pregnancy in 12 patients. The Quarterly journal of medicine, 51(204), 481-497.

17. Bernuau, J., Degott, C., Nouel, O., Rueff, B., & Benhamou, J. P. (1983). Non-fatal acute fatty liver of pregnancy. Gut, 24(4), 340-344.

18. Ringers, J., Bloemenkamp, K. W. M., Francisco, N., Blok, J. J., Arbous, M. S., & Hoek, B. (2016). Auxiliary or orthotopic liver transplantation for acute fatty liver of pregnancy: case series and review of the literature. BJOG: An International Journal of Obstetrics & Gynaecology, 123(8), 1394-1398.

19. Hoare, C. D., Malatjalian, D. A., Bradley, B. W., Sidorov, J. J., & Williams, C. N. (1994). Acute fatty liver of pregnancy. A review of maternal morbidity in 13 patients seen over 12 years in Nova Scotia. Canadian Journal of Gastroenterology, 8(2), 81-87.

Acute Fatty Liver in Pregnancy: Recurrence Rate

Anna C.M. Kluivers^1,2, Ihsane Bougarchouh^1,2, Willy Visser^1,2 and Rugina I. Neuman^1,2

¹Department of Internal Medicine, Division of Pharmacology and Vascular Medicine, Erasmus Medical Center, Rotterdam, The Netherlands

²Department of Gynecology and Obstetrics, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands

Abstract

Background and Purpose: Acute fatty liver of pregnancy (AFLP) is a rare, life threatening complication of pregnancy. Due to its rarity, knowledge regarding risk factors, underlying pathophysiology and recurrence rates are lacking. This study was conducted to evaluate the recurrence rate of AFLP.

Methods: This is a retrospective cohort study at the Erasmus Medical Center in Rotterdam. Medical records of women that were diagnosed with AFLP between 2000 and 2020 were searched regarding index and subsequent pregnancies after patients provided their informed consent. Follow-up was until February 2021.

Results: Thirty-nine women were included in this study. Seventy percent of the women were nulliparous. Thirty-three percent of these women had a full-term subsequent pregnancy. Two patients developed AFLP for a second time after their index pregnancy. In both cases, the course of the disease was milder in the subsequent pregnancy, based on fewer met Swansea criteria and lower AST and ALT values. The recurrence rate was found to be 15 %.

Conclusion: The recurrence rate of AFLP is found to be 15 percent based on this retrospective cohort study.

References

No references.

An Audit of Admissions in Pregnant Patients to a Tertiary Adult Hospital 2016-2021 – Change in Admission Patterns During the Covid-19 Pandemic

L. Madden Doyle¹, R. Varley², D. Lalos² and D. Ryan^1,2

¹Department of Respiratory Medicine, Beaumont Hospital, Beaumont, Dublin 9

²School of Medicine, Royal College of Surgeons in Ireland (RCSI)

Abstract

Background & Purpose: In Ireland, general adult hospitals are often located independently of maternity units. The lack of onsite obstetric input can present a challenge to the general physician due to lack of exposure and training in the management of complex medical conditions in pregnancy.

 The global CoVid-19 pandemic saw a shift in admission rates across many demographics. Our audit sought to identify whether there was any change in medical admission rates, and subspecialty distributions in pregnant women during the CoVid-19 pandemic at our institution.

Methods: This was a retrospective audit of medical admissions 2016 - 2021. Data was collected from medical charts, and discharge summaries on hospital electronic system.

Results: From 2019-2021, there were 55 pregnant patients admitted. 30.1% (n=17) were admitted under respiratory services. 64% (n=11) of these patients were admitted with a diagnosis of CoVid-19, with 7% (n=4) requiring ICU admission.

Discussion: Overall, pregnancy related admissions account for a small percentage of general adult hospital admissions. There was evidence of an increased burden of respiratory admissions during the CoVid-19 pandemic, particularly in the third and fourth quarters of 2021, corresponding with the delta wave in Europe. There was a general shift in admissions during the CoVid era, with a reduction in admissions to non-respiratory services. This is likely secondary to an increased focus on outpatient management during this period.

 This audit highlights data in line with previous international studies, showing the disproportionate burden of severe CoVid-19 in pregnant patients.

 Pregnant patients are a vulnerable group when admitted to non-maternity hospitals. Awareness of medical specialties encountering a higher proportion of patients during pregnancy allows targeting of training, including introduction of specialty-specific diagnostic/therapeutic algorithms, and co-ordination of simulated emergency training.

References

No references.

Assessing the Postpartum Mental Health of Women Who Have Experienced a Hypertensive Disorder of Pregnancy: A Pilot Study

Isha Verma¹, Candice Luo², Meghna Varambally¹, Serena Gundy² and Ryan Van Lieshout³

¹Bachelor's of Health Sciences Program, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

²Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

³Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada

Abstract

Background & Purpose: Hypertensive disorders of pregnancy (HDP) affect up to 10% of individuals globally¹ and are associated with significant stress and an increased risk of complications of pregnancy and delivery. However, detailed longitudinal data on the range of mental health problems affecting this population are lacking. This study seeks to determine the feasibility of assessing broad mental health outcomes in the first postpartum year in those who have experienced HDP.

Methods: We will recruit 50 individuals with a diagnosis of HDP, and 50 without HDP through obstetric and vascular medicine clinics affiliated with McMaster University. We will collect data on symptoms of depression (EPDS), anxiety (GAD-7), and PTSD (PCL-5) at 3, 6, 9 and 12 months postpartum, as well as the psychiatric syndromes assessed by the Mini International Neuropsychiatric Interview (MINI) at 3 and 12 months after delivery.

Results: Baseline data for 47 HDP participants indicate that 72.3% are white, mean age is 33 (SD± 3.70), 95.7% are married/common-law, and mean household income is $124,355 (SD± $65,847). We have completed data collection up to 12 months in 18 cases. While elevated levels of depressive symptoms (EPDS) remained relatively stable through 12 months postpartum (33.3% to 27.8%), rates of major depressive disorder (current) on the MINI increased from 0% to 16.7%. PTSD symptoms (PCL-5) were low on both the questionnaires and MINI. At baseline, 11.1% reported moderate to severe anxiety (GAD-7), which increased to 27.8% at 12 months, and rates of generalized anxiety disorder increased from 5.6% to 16.7% at 12 months.

Conclusion: The study will continue until our sample size is reached. Our preliminary findings suggest that individuals with HDP may experience increasing symptoms of depression and anxiety over the course of the first postpartum year.

Reference

1. Hutcheon JA, Lisonkova S, Joseph KS. Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best practice & research Clinical obstetrics & gynaecology. 2011 Aug 1;25(4):391-403.

Canadian General Internal Medicine Residents’ Perception of a Pedagogical Tool of Online Cases in Obstetric Medicine

Annabelle Cumyn¹ and Nadine Sauvé¹

¹Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada

Abstract

Background & Purpose: Sufficient exposure to rarer medical problems around pregnancy is a challenge during short clinical rotations in obstetric medicine (OM). A Canadian research group created online clinical cases, the CanCOM cases, to overcome this. We conducted an exploratory study to document the use and perceived utility of the CanCOM cases.

Methods: Canadian residents doing an OM rotation were invited to participate in our study. We used a survey to document their perception of CanCOM cases (12 items, 7-point Likert scale), clinical exposure to several conditions (pre and post rotation; 41 items, 7-point Likert scale) and use of the educational tool (1 item, 4-option Likert scale).

Results: A large majority of the N=77 participants (95.6%) indicated that they were motivated or very motivated to use the CanCOM cases and found the online platform to be an accessible and useful tool (6.35±0.89 SD on a 7-point Likert scale). Participants completed a median of 6/20 cases (range 1–20) and stated that they would recommend the cases (6.48±0.73 SD on a 7-point Likert scale). Participants found the cases realistic (6.65±0.49 SD on a 7-point Likert scale) and the key points relevant (6.61±0.58 SD on a 7-point Likert scale). Participants did not feel the need for further discussion with supervisor or colleagues (mean of 3.74 ± 2.12 and 2.91 ± 2.11, respectively on a 7-point Likert scale).

Conclusion: CanCOM cases were shown to contribute to clinical exposure to rare but essential medical conditions. Future development is planned to address the technical limitations, to adapt to other international training settings, add relevant cases for international contexts. A committee with representation of local, national and international Obstetric Medicine societies will guide future development and ensure sustainability.

References

1. Nelson-Piercy C, Peek MJ and Swiet MD. Obstetric physicians: are they needed? The workload of a medical complications in pregnancy clinic. J R Coll Physicians Lond 1995; 30: 150–154.

2. Nelson-Piercy C, Mackillop L, Williams DJ. et al. Maternal mortality in the UK and the need for obstetric physicians. BMJ 2011; 343 :d4993 doi:10.1136/bmj.d4993

3. Magee LA, Cote A-M, Joseph G, et al. Obstetric medical care in Canada. Obstet Med 2016; 9: 117–119.

4. Frederiksen LE, Ernst A, Brix N, et al. Risk of adverse pregnancy outcomes at advanced maternal age. Obstet Gynecol 2018; 131: 457–463.

5. Curtis SL, Marsden-Williams J, Sullivan C, et al. Current trends in the management of heart disease in pregnancy. Int J Cardiol 2009; 133: 62–69.

6. Neggers YH. Trends in maternal mortality in the United States. Reprod Toxicol 2016; 64: 72–76.

7. Grodzinsky A, Florio K, Spertus JA, et al. Maternal mortality in the United States and the HOPE registry. Curr Treat Options Cardiovasc Med 2019; 21: 42.

8. Organization WH. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Published online 2019. https://www.unfpa.org/sites/default/files/pub-pdf/Maternal_mortality_report.pdf

9. Jakes AD, Watt-Coote I, Coleman M, et al. Obstetric medical care and training in the United Kingdom. Obstet Med 2017; 10: 40–42.

10. Card SE, Snell L and O’Brien B. Are Canadian general internal medicine training program graduates well prepared for their future careers? BMC Med Educ 2006; 6: 56.

11. Card SE, Pausjenssen AM and Ottenbreit RC. Determining specific competencies for general internal medicine residents (PGY 4 and PGY 5). What are they and are programs currently teaching them? A survey of practicing Canadian general internists. BMC Res Notes 2011; 4(Journal Article): 480-0500-4-480.

12. Cumyn A and Gibson P. Validation of a Canadian curriculum in obstetric medicine. Obstet Med Med Pregnancy 2010; 3: 145–151.

13. Cumyn A and Harris IB. A comprehensive process of content validation of curriculum consensus guidelines for a medical specialty. Med Teach 2012; 34: e566–e572.

14. Cumyn A, Card SE and Gibson P. Mapping of essential content of an obstetric medicine curriculum from the perspective of two groups. Canadian J General Internal Med 2019: 13–20.

15. Cumyn A, Card SE and Gibson P. Education Research-GIM. Canadian J General Internal Med 2019; 14: 13–29.

16. Dolmans DH, Wolfhagen IH, Essed GG, et al. The impacts of supervision, patient mix, and numbers of students on the effectiveness of clinical rotations. Acad Med 2002; 77: 332–335.

17. Yardley S, Teunissen PW and Dornan T. Experiential learning: transforming theory into practice. Med Teach 2012; 34: 161–164.

18. Cook DA, Hamstra SJ, Brydges R, et al. Comparative effectiveness of instructional design features in simulation-based education: systematic review and meta-analysis. Med Teach 2013; 35: e867–e898.

19. Zendejas B, Brydges R, Wang AT, et al. Patient outcomes in simulation-based medical education: a systematic review. J Gen Intern Med 2013; 28: 1078–1089.

20. Shinnick MA and Woo MA. Learning style impact on knowledge gains in human patient simulation. Nurse Educ Today 2015; 35: 63–67.

21. Zary N, Johnson G, Boberg J, et al. Development, implementation and pilot evaluation of a web-based virtual patient case simulation environment– Web-SP. BMC Med Educ 2006; 6: 1.

22. Wong G, Greenhalgh T and Pawson R. Internet-based medical education: a realist review of what works, for whom and in what circumstances. BMC Med Educ 2010; 10: 1.

23. Kleinpell R, Ely EW, Williams G, et al. Web-based resources for critical care education. Crit Care Med 2011; 39: 541–553.

24. Likert R. A technique for the measurement of attitudes. Arch Psychol. Published online 2010.

25. Bligh J and Bleakley A. Distributing menus to hungry learners: can learning by simulation become simulation of learning? Med Teach 2006; 28: 606–613.

26. Jeffries PR. A framework for designing, implementing, and evaluating: simulations used as teaching strategies in nursing. Nurs Educ Perspect 2005; 26: 96–103.

27. O’Donnell JM, Decker S, Howard V, et al. NLN/Jeffries simulation framework state of the science project: simulation learning outcomes. Clin Simul Nurs 2014; 10: 373–382.

Cardiovascular Preventive Clinical Care Following Hypertensive Disorders of Pregnancy: A Systematic Review

Brianna Ghali, BSc¹, Colleen Norris, PhD^2,3, Sapna Chawla, MBA⁴, Judeah Negre, BSc⁴ and Kara Nerenberg, MD^5,6

¹University of Calgary Cumming School of Medicine, Calgary, Canada

²Faculty of Nursing, Cardiovascular Health and Stroke Strategic Clinical Network, Canada

³Faculty of Medicine & Dentistry and School of Public Health, University of Alberta, Edmonton, Canada

⁴Libin Cardiovascular Institute, University of Calgary, Canada

⁵Chair University of Calgary Departments of Medicine, Obstetrics & Gynecology and Community Health Sciences

⁶Heart and Stroke Foundation & CIHR

Abstract

Background & Purpose: People who experience a hypertensive disorder of pregnancy (HDP) have high risks of cardiometabolic multimorbidity within 5-10 years post-delivery, which are largely preventable through early interventions. Current post-partum care is not sufficient in treatment and prevention of cardiometabolic disease. The objective of this study was to evaluate the state of the science on postpartum clinical care focused on cardiovascular risk reduction as a first step in informing a national health promotion strategy tailored for high-risk people after HDP.

Study Methods: A systematic review of the literature was performed. Databases searched included Medline, Embase, Emcare and Cochrane from inception to Jan 2021. All primary studies that described any postpartum clinical care after HDP through either healthcare systems interventions or specialized clinics were included.

Results: Nine studies met the inclusion criteria. Two studies described interdisciplinary postpartum clinics specifically tailored for the early postpartum period. Clinics provided individualized education about health behaviours and pharmaceutical treatments to lower participant’s future risks of cardiometabolic diseases. Follow-up rates were low across all interventions ranging from 27 to 79% for the first visit due to gender-related barriers to care. Little-to-no follow up continue beyond 1-year postpartum. Other interventions included health systems’ approaches and education materials.

Conclusion: While there is significant cardiometabolic morbidity associated after experiencing HDPs, there remains a paucity of evidence describing effective clinical and systems-level interventions to ensure adequate follow-up of these high-risk people, either in specialized clinics or primary care. There is an important need for future research to focus on developing effective, standardized, gender-transformative follow-up interventions to prevent cardiometabolic disorders, and to ensure that all Canadians after HDP receive evidence-based preventive care.

References

1. Lewey, J., Levine, L. D., Yang, L., Triebwasser, J. E., & Groeneveld, P. W. (2020). Patterns of postpartum ambulatory care follow-up care among women with hypertensive disorders of pregnancy. Journal of the American Heart Association, 9(17), e016357.

2. Bittle, M. D., Scalise, L., Green, D., Srinivas, S., Hirshberg, A., & Chandrasekaran, S. (2014). The High-Risk Postpartum Transitional Program: A multidisciplinary approach to caring for postpartum woman with hypertensive disease. Journal of Obstetric, Gynecologic & Neonatal Nursing, 43, S16.

3. Parfenova, M., Côté, A. M., Cumyn, A., Pesant, M. H., Champagne, M., Roy-Lacroix, M. È., … & Sauvé, N. (2021). Impact of an educational pamphlet on knowledge about health risks after hypertensive disorders of pregnancy: a randomized trial. Journal of Obstetrics and Gynaecology Canada, 43(2), 182-190.

4. Yu, J., Pudwell, J., Dayan, N., & Smith, G. N. (2020). Postpartum breastfeeding and cardiovascular risk assessment in women following pregnancy complications. Journal of Women's Health, 29(5), 627-635.

5. Janmohamed, R., Montgomery-Fajic, E., Sia, W., Germaine, D., Wilkie, J., Khurana, R., & Nerenberg, K. A. (2015). Cardiovascular risk reduction and weight management at a hospital-based postpartum preeclampsia clinic. Journal of Obstetrics and Gynaecology Canada, 37(4), 330-337.

6. Van Kesteren, F., Visser, S., Hermes, W., Franx, A., Van Pampus, M. G., Poppel, M. N., … & De Groot, C. J. (2015). Prevention of cardiovascular risk in women who had hypertension during pregnancy after 36 weeks gestation. Hypertension in Pregnancy, 34(2), 261-269.

7. Gladstone, R. A., Pudwell, J., Pal, R. S., & Smith, G. N. (2019). Referral to cardiology following postpartum cardiovascular risk screening at the maternal health clinic in Kingston, Ontario. Canadian Journal of Cardiology, 35(6), 761-769.

8. Celi, A. C., Seely, E. W., Wang, P., Thomas, A. M., & Wilkins-Haug, L. E. (2019). Caring for women after hypertensive pregnancies and beyond: implementation and integration of a postpartum transition clinic. Maternal and child health journal, 23(11), 1459-1466.

COVID-19 in Pregnancy: Patterns of Community and Hospital Infection and Maternal Outcomes in Oxfordshire, UK

Charlotte Frise¹, Bethan Percival¹ and Justyna Pordzik¹

¹Obstetrics Department, Oxford Univeristy Hospital NHS Foundation Trust, Oxford, UK

Abstract

Background & Purpose: Pregnant women with COVID-19 are at higher risk of severe disease than non-pregnant women of the same age^1,2. Unvaccinated individuals are at substantially greater risk^3,4. Much data published focuses on women hospitalized with moderate to severe infection. Outcomes of pregnant women with mild COVID-19 managed in the community are less well described, in part due to the system by which UK COVID results were reported. This study aims to analyze maternal outcomes of women with COVID-19, particularly those with mild infection, and look at patterns of vaccination and infection in Oxfordshire, UK.

Methods: This is a regional population-based prospective observational cohort study of 1012 pregnant women with COVID-19. Community and hospital cases were reported to a central database and electronic patient records used to collect demographic and pregnancy outcome data. This enabled a large cohort of women with mild COVID-19, managed in the community, to be assessed who may have otherwise not been included in analysis.

Results: We found 96.6% of our patients had mild COVID-19 and did not require admission to hospital. Data shows that in Oxfordshire the population is older, with fewer women from black and minority ethnicities than COVID-19 data published nationally³. There are also lower rates of smoking and obesity. 62% of the cohort were vaccinated but when analyzed by ethnicity, only 28% of Black women and 49% Asian women were vaccinated. Most patients requiring admission to hospital were unvaccinated. Of those community cases with mild COVID-19 there were no adverse maternal outcomes reported.

Conclusion: We demonstrate that COVID-19 in pregnancy frequently presents as a mild infection with no adverse maternal outcomes. High vaccination rates and a predominantly Caucasian population are likely to have been protective in our Oxfordshire cohort. Promotion of COVID-19 vaccine uptake particularly amongst groups most at risk is essential.

References

1. Allotey J, Fernandez S, Bonet M, Stallings E, Yap M, Kew T 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 :m3320 doi:10.1136/bmj.m3320

2. Nana M, Hodson K, Lucas N, Camporota L, Knight M, Nelson-Piercy C et al. Diagnosis and management of covid-19 in pregnancy BMJ 2022; 377 :e069739 doi:10.1136/bmj-2021-069739

3. Knight M, Bunch K, Vousden N, Morris E, Simpson N, Gale C et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study BMJ 2020; 369 :m2107 doi:10.1136/bmj.m2107

4. Mahase E. Covid-19: Vaccine uptake during pregnancy has increased but deprived areas lag behind, data show BMJ 2021; 375 :n2932 doi:10.1136/bmj.n2932

COVID-19 in Women – Is it Different in Pregnancy?

Meena Khandelwal, MD⁵, BriarRose Ginn, BA¹, Saba Daneshpooy, BS², Tina Edmonston, MD³, Dejan Nikolic, MD, PhD³, Monica Ianosi-Irimie, MD, PhD³ and Krystal Hunter, PhD MBA⁴

¹Medical Student, MS-3, Cooper Medical School of Rowan University, Camden, NJ, USA

²Medical Student, MS-4, Cooper Medical School of Rowan University, Camden, NJ, USA

³Department of Pathology and Laboratory Services, Cooper University Healthcare, Camden, NJ, USA

⁴Biostatician, Cooper Research Institute, Cooper Medical School of Rowan University, Camden, NJ, USA

⁵Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, Cooper University Healthcare, Camden, NJ, USA

Abstract

Background and Purpose: Effects of COVID-19 in pregnancy are controversial.^1-3 Some studies have found that a high viral load (VL) yields more symptoms,^3,4 while others have found no significant differences.⁵ Some studies have shown pregnant women are not more likely to have a serious illness,^2,6,7 while others say pregnancy is at risk for severe disease.^8,9 The purpose of our study is to compare VL values of polymerase chain reaction (PCR) tests between COVID-19 positive pregnant and nonpregnant women. Our secondary aim is to compare the asymptomatic rates among these two groups.

Methods: This case-control study identified women with COVID-19 confirmed by PCR between April-November, 2020. Cycle threshold (Ct), the number of cycles run on PCR to detect COVID-19, is inversely proportional to VL. Each pregnant woman was matched, by BMI and age, to two nonpregnant controls. Statistical analyses included Independent T-Test, Cochran's Q test and repeated measures ANOVA.

Results: Sixty-four pregnant women were matched to 128 nonpregnant female controls. Race did not differ between the two groups. Ct in asymptomatic cases (Ct=24.1, SD=5.9) was higher (lower viral load) than symptomatic cases (Ct=12.5, SD=7.3) (p<0.001). Ct did not differ between pregnant and non-pregnant females, regardless of symptoms.

Symptomatic infection among pregnant women was 54% compared to 87.7% in nonpregnant women (p<0.001). Fever, cough and fatigue were less common in pregnancy, at rates of 20.3% vs 40.7% (p=0.03), 39.1% vs 61.7% (p=0.02), and 4.7% vs 19.6% (p=0.02), respectively. Rates of shortness of breath, loss of taste and/or smell were similar in the two groups.

Conclusion: Pregnancy did not yield higher viral load than nonpregnancy. VL is higher in symptomatic women than asymptomatic women, which holds true in pregnancy as well. Of all hospital admissions, pregnant women were less symptomatic than nonpregnant women. Correlation between VL and severity of disease needs further investigation.

References

1. Salem, D., Katranji, F., & Bakdash, T. (2020). COVID-19 infection in pregnant women: Review of maternal and fetal outcomes. International Journal of Gynecology & Obstetrics, 152, 291-298.

2. Selim, M., Mohamed, S., Abdo, M., & Abdelhaffez, A. (2020). Is COVID-19 Similar in Pregnant and Non-Pregnant Women?. Cureus, 12(6)

3. Walsh, K. A., Jordan, K., Clyne, B., Rohde, D., Drummond, L., Byrne, P., et al. (2020). SARS-CoV-2 detection, viral load and infectivity over the course of an infection: SARS-CoV-2 detection, viral load and infectivity. Journal of Infection, 81:357-371.

4. Pujadas, E., Chaudhry, F., McBride, R., Richter, F., Zhao, S., Wajnberg, A., … & Cordon-Cardo, C. (2020). SARS-CoV-2 viral load predicts COVID-19 mortality. The Lancet. Respiratory medicine, 8(9), e70.

5. Buchan, B. W., Hoff, J. S., Gmehlin, C. G., Perez, A., Faron, M. L., Munoz-Price, L. S., & Ledeboer, N. A. (2020). Distribution of SARS-CoV-2 PCR cycle threshold values provide practical insight into overall and target-specific sensitivity among symptomatic patients. American Journal of Clinical Pathology, 154(4), 479-485.

6. Dória, M., Peixinho, C., Laranjo, M., Varejão, A. M., & Silva, P. T. (2020). Covid-19 during pregnancy: a case series from an universally tested population from the north of Portugal. European Journal of Obstetrics and Gynecology and Reproductive Biology.

7. Bachani, S., Arora, R., Dabral, A., Marwah, S., Anand, P., Reddy, K. S., … & Singh, B. (2021). Clinical profile, viral load, maternal-fetal outcomes of pregnancy with COVID-19: 4-week retrospective, tertiary care single-centre descriptive study. Journal of Obstetrics and Gynaecology Canada, 43(4), 474-482.

8. Prabhu, M., Cagino, K., Matthews, K. C., Friedlander, R. L., Glynn, S. M., Kubiak, J. M., … & Riley, L. E. (2020). Pregnancy and postpartum outcomes in a universally tested population for SARS-CoV-2 in New York City: a prospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 127(12), 1548-1556.

9. Khoiwal, K., Agarwal, A., Gaurav, A., Kumari, R., Mittal, A., Sabnani, S., … & Chaturvedi, J. (2022). Obstetric and perinatal outcomes in pregnant women with COVID-19: an interim analysis. Women & health, 62(1), 12-20.

Hypertension and Serum Sodium Concentrations Above 140mmol/L in Pregnancy as a Predictor of Primary Aldosteronism

Adeela Ashraf¹, William M Drake², Morris J Brown³, Kate Wiles⁴

¹Royal London Hospital, Barts Health NHS Trust, London, UK

²Department of Endocrinology, St Bartholomew’s Hospital, London, UK

³Endocrine Hypertension, Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK

⁴Physician Lead for the North-East London Maternal Medicine Network; Departments of Renal Medicine and Women's Health, Barts Health NHS Trust, London, UK

Abstract

Background and Purpose: Chronic hypertension affects 10% of pregnancies¹, and 20% of hypertension is diagnosed for the first time in pregnancy. Primary aldosteronism (PA) is the most common cause (14%) of reversible hypertension, and pregnancy is a recognised trigger for presentation². However, it is rarely (<1%) diagnosed, with limited data to target post-partum investigation³. This study examined the association between serum electrolyte concentrations in pregnancy and post-partum diagnosis of PA.

Methods: A retrospective cohort study of serum electrolyte concentrations in chronic hypertension in pregnancy compared to hypertension in pregnancy subsequently diagnosed as PA, using Mann Whitney-U and T-tests. Where measurable differences were detected, an area under the ROC curve was generated and Youden’s index used to generate a diagnostic threshold value.

Results: The study included 157 women with chronic hypertension compared to 12 women with a post-partum diagnosis of PA. Electrolyte concentrations were available in 27, 112 and 112 pregnancies in the first, second and third trimesters respectively. Serum sodium was higher in pregnancy in PA (139.5 versus 137.0 mmol/L; p=0.0007). This difference was measurable in the first (141.0 versus 137.0 mmol/L; p=0.0075) and third (139.5 vs 138.0; p=0.012) trimesters, but not in the second (139.0 vs 137.0; p=0.23) trimester. The area under the ROC curve for serum sodium was 0.77 (95% CI: 0.62-0.91). A serum sodium of 140 mmol/L or more in pregnancy predicted post-partum diagnosis of PA with specificity of 87%. There was no measurable difference in gestational serum potassium in women with PA

Conclusion: Serum sodium concentrations in pregnancy are higher in women later diagnosed with PA. A sodium of 140 mmol or more may have clinical utility in identifying women for post-partum investigation of PA. Serum potassium concentrations in pregnancy do not distinguish PA. Prospective data are required.

References

1. Hutcheon et al. Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol. 2011; 25(4):391-403.

2. Zhou et al. Somatic mutations of GNA11 and GNAQ in CTNNB1-mutant aldosterone-producing adenomas presenting in puberty, pregnancy or menopause. Nat Genet 2021; 53(9):1360-72.

3. Malha L and August P. Secondary Hypertension in Pregnancy. Curr Hypertens Rep. 2015; 17(7):53.

Hypertensive Disorders of Pregnancy Counselling Practices of Antenatal and Postpartum Health Care Providers in Ontario: A Mixed Methods Study

Giuliana Guarna¹, Jeffrey Sun² and Serena Gundy³

¹Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.

²Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.

³Obstetric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Abstract

Background/Purpose: Hypertensive disorders of pregnancy (HDP) affect approximately 7% of all pregnancies in Canada (1,2). Women with HDP are at higher risk for postpartum development of; traditional cardiovascular risk factors, cardiovascular disease, and have increased mortality in both the short and long-term (3,4,5,6,7). Prior research demonstrates a lack of awareness of both patients and health care providers leading to a missed opportunity for knowledge translation and intervention. Our aim is to understand barriers, enablers, and knowledge gaps that influenced patients and providers caring for women with HDP in Ontario, Canada.

Methods: A mixed methods design using a sequential, explanatory approach. Patient surveys were administered using an online platform (RedCap). Semi-structured interviews will be conducted to understand the perspectives of healthcare providers (midwives, family physicians, obstetricians) in greater detail. Survey data will be analyzed using descriptive statistics, and thematic analysis used for generating codes, categories and themes from the interview data. Interview data will be triangulated with survey data.

Results: 68 patients started the survey, partial responses were analyzed. 98% of patients delivered in Southern Ontario. Only 53% (N = 26) of patients were notified during pregnancy that they could develop HTN in future, 69% (N = 33) were told postpartum. 66% (N=32) were aware that having HDP placed them at higher risk for future CVD, with N=17 being told this by an Ob/Gyn and N=15 knowing this from a self-internet search. Health care providers are currently being recruited for focus groups and resulting data will be analyzed as it is generated.

Conclusion: Patients remain underinformed about subsequent cardiovascular risks after having a hypertensive disorder of pregnancy. Barriers and facilitators with respect to healthcare provider counselling practices will be further elucidated using qualitative study design. A more wholesome understanding of this issue can lead to targeted and effective knowledge translation efforts.

References

1. Butalia, S., Audibert, F., Anne-Marie, Firoz, T., Logan, A. G., Magee, L. A., . . . Nerenberg, K. A. (2018). Hypetension Canada's 2018 Guidelines for the Management of Hypertension in Pregnancy . Canadian Journal of Cardiology, 34, 526-531.

2. Varin, M., Baker, M., Palladino, E., & Lary, T. (2019, October). Canadian Chronic Disease Indicators, 2019 - Updating the data and taking into account mental health. Health Promotion and Chronic Disease Prevention in Canada , 39(10), 281-288.

3. Smith, G. N., Louis, J. M., & Saade, G. R. (2019, October). Pregnancy and the Postpartum Period as an Opportunity for Cardiovascular Risk Identification and Management. Obstetrics and Gynecology, 134(4), 851-862.

4. Fraser, A., Nelson, S. M., Macdonald-Wallis, C., Cherry, L., Butler, E., Sattar, N., & Lawlor, D. A. (2012, March 20). Associations of Pregnancy Complications with Calculated Cardiovascular Disease Risk and Cardiovascular Risk Factors in Middle Age. Circulation, 1367-1380.

5. Ahmed, R., Dunford, J., Mehran, R., Robson, S., & Kunadian, V. (2014). Pre-Eclampsia and Future Cardiovascular Risk Among Women A Review. Journal of the American College of Cardiology, 63(18), 1815-22.

6. Ray, J. G., Vermeulen, M. J., Schull, M. J., & Redelmeier, D. A. (2005, November 19). Cardiovascular health after maternal placental syndrome (CHAMPS): population-based retrospective cohort study. Lancet, 366, 1797-1803.

7. Lane-Cordova, A. D., Khan, S. S., Grobman, W. A., Greenland, P., & Shah, S. J. (2019, April 2019). Long- Term Cardiovascular Risks Associated with Adverse Pregnancy Outcomes. Journal of the American College of Cardiology, 73(16), 2106-16.

Implementation of an Obstetric Medicine Teaching Series Within an NHS Hospital Trust

Yasmin Hazemi-Jebelli¹, Soomin Jang², Laura Harrington³, Nanci O'Reilly⁴ and Shaznin Visanji⁵

¹Acute Internal Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, England

²Acute Internal Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, England

³Registrar, Acute Internal Medicine Registrar, Barking, Havering and Redbridge University Hospitals NHS Trust, London, England

⁴Registrar, Acute Internal Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, England

⁵Consultant in Acute Internal Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, England (corresponding author)

Abstract

Background & Purpose: Obstetric medicine forms an important principle of General Internal Medicine (GIM). Heart disease remains the leading cause of death in patients who are pregnant (and up to 6 weeks post-partum) followed by epilepsy and stroke, alongside mental health problems ^[1]. The Internal Medicine Training (IMT) and GIM curricula includes the management of medical problems in pregnancy, both pre-existing and as a direct complication of pregnancy.

Method and Results: A survey was sent out to gauge the pre-existing training opportunities, if any, on managing pregnant or post-partum patients presenting with medical problems. This was sent to doctors across multiple levels and specialties. Of 29 responses:

• 75.9% said they had no prior formal teaching in managing obstetric cases

• 55.2% said they had no confidence at all in managing obstetric medicine cases and patients

• 100% said a lecture-based series would be helpful

An Obstetric Medicine teaching series has been implemented covering the following:

• Introduction to Obstetric Medicine

• Cardiology in Obstetric Medicine

• Case based teaching: Gastrointestinal and Renal cases

• Case based teaching: Neurology and Respiratory Cases

• Obstetric specific Complications

These form an optional in-person or virtual lunchtime teaching session, led by specialists in obstetric medicine. The program is now well under way, with attendance and feedback thus far showing a very positive response to case-based elements and the interactivity of the sessions.

Discussion: There is a need for formal teaching on managing medical problems within pregnancy to ensure safe care for this cohort of patients to prevent maternal death and disease.

Conclusion: There is a lack of confidence in managing medical complications in pregnancy, including in doctors who are involved in the acute medical take. Formal teaching through a structured program is likely to improve the trainee’s experience in managing these patients in the acute setting, potentially translating to improved patient care for pregnant women.

Reference

1. Knight M, Bunch K, Tuffnell D, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2021.

Improving Obstetric Medicine Education in Residency

Xinglin (Lyn) Li¹, Shital Gandhi^1,2 and Yayi Huang¹

¹University of Toronto

²Mount Sinai Hospital

Abstract

Background & Purpose: Maternity care in Canada is provided by Obstetricians, Family Practitioners, and midwives, but with trends of increasing chronic conditions and delayed childbirth, Internal Medicine (IM) specialists are often consulted to co-manage maternal diseases in pregnancy. Previous studies showed unpreparedness in IM residents in treating pregnant patients due to inadequate training and exposure¹. Effective methods in improving education in this area include didactic lectures, cases, and dedicated women’s health curriculums^2,3,4,5. The goal of this study is to identify gaps in resident medical education of pregnant patients to enhance competency and ultimately improve health outcomes.

Methods: This is a prospective quantitative and qualitative needs-assessment study. Study participants included second to fifth year residents in the Toronto IM program. All participants completed a questionnaire including exposure to pregnant patients, preparedness to treat diseases in pregnancy, and usefulness of the Obstetric Medicine handbook.

Results: 49 residents were included in this study. 69.4% reported having seen or treated <10 pregnant patients so far in residency. 87.7% reported having <10 hours of lectures on the medical diseases of pregnancy. 47% rated resident education in this topic below average or poor, 51% felt knowledge in this area was important, 71.4% felt uncomfortable managing medical disorders in pregnancy with their existing knowledge. 57.1% were aware of the Obstetrics Medicine Handbook, of those 89.4% found it a useful resource. General feedback suggested more half days, simulation-based learning, and increasing exposure through subspecialty clinics or mandatory Obstetrics Medicine rotations.

Conclusion: There is currently inadequate exposure, preparedness, and training in Obstetric Medicine experienced by senior IM residents at the University of Toronto. Overall reception to the Obstetrics Medicine Handbook was positive. Suggestions to improve include increased didactic lectures, simulations, and more clinical exposure. Further research is needed to study these strategies to improve resident training in caring for pregnant patients.

References

1. Spagnoletti CL, Rubio DM, McNeil MA. Internal medicine residents' preparedness to care for reproductive-age and pregnant women. Teach Learn Med. 2007;19(3):257-263.

2. Powrie R, Kweder S, Rosene-Montella K. Teaching internal medicine residents about medical problems in pregnancy. Acad Med. 2000;75(2):191-193.

3. Spagnoletti CL, Sanders AM, McGee JB, Bost JE, McNeil MA. Teaching internal medicine residents to care for reproductive-age and pregnant women: an effective Web-based curriculum. Teach Learn Med. 2008;20(2):186-192.

4. Davisson L, Nuss M, Cottrell S. Women's Health Curriculum for Internal Medicine Residents: Development, Implementation, and Evaluation. J Grad Med Educ. 2010;2(3):398-403.

5. Spencer AL, Bost JE, McNeil M. Do Women's health internal medicine residency tracks make a difference?. J Womens Health (Larchmt). 2007;16(8):1219-1223.

Implementation of a Home Blood Pressure Monitoring Program for Management of Hypertensive Disorders of Pregnancy, a Quality Improvement Study, in British Columbia, Canada

Karen C. Tran^1,2, Sabina Freiman³, Tessa Chaworth¹, Susan Purkiss¹, Colleen Foster¹, Nadia A. Khan^1,2, Wee Shian Chan¹

¹Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver Canada

²Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada

³Internal Medicine Residency Training Program, University of British Columbia, Vancouver, Canada

Abstract

Background & Purpose: Home blood pressure monitoring (HBPM) in pregnant women is common, but uncertainty exists on utilization of home blood pressure (BP) readings for management of hypertensive disorders of pregnancy (HDP). We conducted a qualitative improvement study to understand how physicians utilize HBPM for pregnant patients and patient acceptability.

Methods: Pregnant patients with risk factors for HDP were recruited. Participants were provided with a validated home BP monitor (Microlife Watch BP) and monitored their BP two times in the morning/evening and manually entered data into a paper diary. Obstetrical Medicine physicians completed written survey after each clinic visit to understand how they used HBPM. Surveys were sent to all participants to assess acceptability of HBPM.

Results: In total, 103 women were recruited for the study, of which, 43% were enrolled antepartum (mean age 34±5 years; mean gestation 171±61 days) and 57% postpartum (mean age 35±6 years; mean days postpartum 6±4 days). Median compliance with home BP readings was 0.94 (IQR 0.57, 1.00). Obstetrical Medicine physicians relied on the range of HBPM readings (70%) to make clinical decisions for management of HDP. Antepartum, 13% of clinic visits resulted in an increase of anti-hypertensive medications, and 82% required no change in medication. Post-partum, 44% of visits required a decrease anti-hypertensive medication. 98% of participants found HBPM easy to do, and 51% were able to strictly adhere to their measurement schedule. Barriers to HBPM included newborn care (57%), forgetting to check (39%), and lack of time in the mornings (35%).

Conclusion: HBPM to manage HDP is acceptable to patients and can be safely used to manage HDP ante-partum and post-partum. In light of the COVID-19 pandemic and increasing demand for virtual healthcare visits, further studies are need to assess the effectiveness of HBPM on management of HDP.

References

1. Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol. 2009;33(3):130-7.

2. Brown MC, Best KE, Pearce MS, Waugh J, Robson SC, Bell R. Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis. Eur J Epidemiol. 2013;28(1):1-19.

3. Krause T, Lovibond K, Caulfield M, McCormack T, Williams B, Guideline Development G. Management of hypertension: summary of NICE guidance. BMJ. 2011;343:d4891.

4. Nerenberg KA, Zarnke KB, Leung AA, Dasgupta K, Butalia S, McBrien K, et al. Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. Can J Cardiol. 2018;34(5):506-25.

5. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens. 2018;36(10):1953-2041.

6. Whelton PK, Carey RM, Aronow WS, Casey DE, Jr., Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138(17):e484-e594.

7. Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, et al. European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. J Hypertens. 2008;26(8):1505-26.

8. Dehaeck U, Thurston J, Gibson P, Stephanson K, Ross S. Blood Pressure Measurement for Hypertension in Pregnancy. Journal of Obstetrics and Gynaecology Canada. 2010;32(4):328-34.

9. Tran K, Potts J, Robertson J, Ly K, Dayan N, Khan N, et al. Out-of-office blood pressure measurement for the diagnosis of hypertension in pregnancy: Survey of Canadian Obstetric Medicine and Maternal Fetal Medicine specialists. Obstetric Medicine.0(0):1753495X18819338.

10. Tremonti C, Beddoe J, Brown MA. Reliability of home blood pressure monitoring devices in pregnancy. Pregnancy Hypertens. 2017;8:9-14.

11. Tran KC PR, Khan N, Chan WS. Home blood pressure monitoring in the diagnosis and management of hypertension in pregnant women: A systematic review and meta-analysis. Manuscript in preparation. 2019.

12. Tran K, Padwal R, Khan N, Wright MD, Chan WS. Home blood pressure monitoring in the diagnosis and treatment of hypertension in pregnancy: a systematic review and meta-analysis. CMAJ Open. 2021;9(2):E642-E50.

13. Tucker KL, Mort S, Yu LM, Campbell H, Rivero-Arias O, Wilson HM, et al. Effect of Self-monitoring of Blood Pressure on Diagnosis of Hypertension During Higher-Risk Pregnancy: The BUMP 1 Randomized Clinical Trial. JAMA. 2022;327(17):1656-65.

14. Chappell LC, Tucker KL, Galal U, Yu LM, Campbell H, Rivero-Arias O, et al. Effect of Self-monitoring of Blood Pressure on Blood Pressure Control in Pregnant Individuals With Chronic or Gestational Hypertension: The BUMP 2 Randomized Clinical Trial. JAMA. 2022;327(17):1666-78.

15. Magee LA, von Dadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407-17.

16. Tucker K, Hodgkinson J, Wilson H, et al.. Current prevalence of self-monitoring of blood pressure during pregnancy: the BUMP Survey. Journal of Hypertension. 2021;39(5):994-1001.

Maternal and Fetal Outcomes of Pregnancy in the Setting of Maternal Cardiovascular Disease, Managed by Multidisciplinary Care in Manitoba

Sarah Gibbs¹, Robin Ducas², Jennifer Hunt³ and Christopher Labos⁴

¹Department of Internal Medicine, University of Manitoba, Winnipeg, Canada

²Department of Cardiology, University of Manitoba, Winnipeg, Canada

³Department of Obstetrics and Gynecology, University of Manitoba, Winnipeg, Canada

⁴Queen Elizabeth Health Complex, Montreal, Quebec

Abstract

Background and Purpose: Access to specialized care can improve outcomes for mother and fetus in the setting of maternal cardiac disease, however distance to care has not been evaluated in cardio-obstetric outcomes. The objective of our study was to characterize the maternal and fetal outcomes at our center, covering a large geographic area.

Methods: A retrospective cohort study for cardio-obstetric patients cared for at the tertiary centre in Winnipeg, Manitoba, Canada was carried out between March 2018-March 2021. Data was included for all patients where both maternal and fetal outcome data was available.

Results: We included 112 viable pregnancies and 114 liveborn neonates. Maternal cardiac pathology: congenital (38%) and acquired heart disease (44%). Forty-one (36 %) patients lived outside Winnipeg, where cardio-obstetric care was provided. The average distance from Winnipeg was 381km, with the farthest distance being 1604 km. The most common mWHO score was II (25%). Thirty pregnancies (27%) experienced an adverse cardiac event, with one postpartum maternal death related to peripartum cardiomyopathy. Most infants were born at term (81%). There were no cases of fetal/ neonatal death. Twenty neonates (17%) required admission to the neonatal intensive care unit. Six infants (5.2%) experienced an adverse neonatal event.

Multivariate analysis demonstrated that the presence of acquired heart disease predicted maternal adverse cardiac events (OR of 6.7, 95% confidence interval 1.48 to 29.84, p = 0.013). In addition, late presentation to care (>20 weeks) predicted adverse fetal outcomes (OR of 3.88, 95% confidence interval 1.08 to 13.89, p = 0.037). Distance from the specialized care center was not associated with any adverse outcome.

Conclusion: Patients with acquired heart disease had worse maternal outcomes, while late presentation to care predicted worse fetal outcomes. Distance from our multidisciplinary care site was not associated with worse maternal, fetal or neonatal outcomes in this study.

References

1. Creanga, A. A., Syverson, C., Seed, K., & Callaghan, W. M. (2017). Pregnancy-Related Mortality in the United States, 2011-2013. Obstetrics and Gynecology, 130(2), 366–373. https://doi.org/10.1097/AOG.0000000000002114

2. Keepanasseril, A., Pfaller, B., Metcalfe, A., Siu, S. C., Davis, M. B., & Silversides, C. K. (2021). Cardiovascular Deaths in Pregnancy: Growing Concerns and Preventive Strategies. Canadian Journal of Cardiology, 37(12), 1969–1978. https://doi.org/10.1016/J.CJCA.2021.09.022

3. Khan, K. S., Wojdyla, D., Say, L., Metin Gülmezoglu, A., & A Van Look, P. F. (2006). Articles WHO analysis of causes of maternal death: a systematic review. Www.Thelancet.Com, 367. https://doi.org/10.1016/S0140-6736(06)

4. Shapero, K. S., Desai, N. R., Elder, R. W., Lipkind, H. S., Chou, J. C., & Spatz, E. S. (2020). Cardio-obstetrics: Recognizing and managing cardiovascular complications of pregnancy. Cleveland Clinic Journal of Medicine, 87(1), 43–52. https://doi.org/10.3949/ccjm.87a.18137

5. Silversides, C. K., Grewal, J., Mason, J., Sermer, M., Kiess, M., Rychel, V., Wald, R. M., Colman, J. M., & Siu, S. C. (2018). Pregnancy Outcomes in Women With Heart Disease: The CARPREG II Study. Journal of the American College of Cardiology, 71(21), 2419–2430. https://doi.org/10.1016/J.JACC.2018.02.076

Maternal and Perinatal Outcomes in Recurrent Gestational Diabetes (rGDM) – Implications for Screening, Monitoring and Management

JM Thornton^1,2, T Liney³, NM Shah^1,2, W Cui², MR Johnson^1,2 and N Singh^1,2

¹Department of Obstetrics & Gynaecology, Chelsea & Westminster NHS Foundation Trust, London, UK

²Department of Metabolism, Digestion and Reproduction, Imperial College London, UK

³Imperial College Healthcare NHS Trust, London, UK

Abstract

Background & Purpose: GDM is a common metabolic disorder[1], characterized by pregnancy-induced dysregulation of glucose homeostasis feedback systems[2]. Mothers with GDM have a 30-40% rGDM rate[3] and a 40-60% increased risk of developing type 2 diabetes and cardiovascular disease in the following 10 years[4, 5]. Increasingly, it is thought that GDM can induce stable epigenetic modifications in the offspring, and therefore a lifelong increased risk of cardiometabolic disorders[6, 7]. Prompt identification and treatment of GDM may modify these risks. However, debate remains as to the optimum rGDM screening method. In our unit, we offer all women early blood glucose monitoring (eBGM) in subsequent pregnancies, and so undertook a retrospective study on maternal and perinatal outcomes in our cohort.

Methods: Single-centre retrospective observational study including women with rGDM delivering from 29/02/2020 to 24/05/2021. Antecedent pregnancy data included those whom delivered from 22/4/14 to 03/10/20. Women were identified and data obtained for statistical analysis through online maternity databases.

Results: 51 women with rGDM were identified from the dataset, encompassing 109 pregnancies. There were no statistically significant differences in booking BMI, HbA1c at diagnosis, rates of induction of labour, or birth weight in subsequent pregnancies. Though requirement for pharmacological management became more likely as GDM recurred (p=0.037), rates of maternal and perinatal complications decreased (P= 0.007, P=0.02, respectively).

Conclusion: The decreasing rate of maternal and perinatal complications observed may be attributed to increased rates of pharmacological management of GDM in the context of a stable BMI across pregnancies. We hypothesise that by screening and treating women earlier, we reduce the impact of metabolic dysregulation and therefore adverse health outcomes for mothers and their offspring [8]. We intend to undertake a randomized study of eBGM compared to later screening tests, such that we can ascertain how we may best improve metabolic health for women and their children.

References

1. Farrar, D., et al., The identification and treatment of women with hyperglycaemia in pregnancy: an analysis of individual participant data, systematic reviews, meta-analyses and an economic evaluation. Health Technol Assess, 2016. 20(86): p. 1-348.

2. Enninga, E.A.L., et al., Frequency of Gestational Diabetes Mellitus Reappearance or Absence during the Second Pregnancy of Women Treated at Mayo Clinic between 2013 and 2018. Journal of Diabetes Research, 2019. 2019: p. 1-7.

3. Morikawa, M., et al., Predictors of recurrent gestational diabetes mellitus: A Japanese multicenter cohort study and literature review. Journal of Obstetrics and Gynaecology Research, 2021. 47(4): p. 1292-1304.

4. Bellamy, L., et al., Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet, 2009. 373(9677): p. 1773-9.

5. Kim, C., K.M. Newton, and R.H. Knopp, Gestational Diabetes and the Incidence of Type 2 Diabetes. Diabetes Care, 2002. 25(10): p. 1862-1868.

6. Hjort, L., et al., Gestational diabetes and maternal obesity are associated with epigenome-wide methylation changes in children. JCI Insight, 2018. 3(17).

7. Yang, I.V., et al., Epigenetic marks of in utero exposure to gestational diabetes and childhood adiposity outcomes: the EPOCH study. Diabet Med, 2018. 35(5): p. 612-620.

8. Antoun, E., et al., Maternal dysglycaemia, changes in the infant's epigenome modified with a diet and physical activity intervention in pregnancy: Secondary analysis of a randomised control trial. PLoS Med, 2020. 17(11): p. e1003229.

Moderate to Severe COVID-19 Illness in Pregnancy: The Experience in a Tertiary Centre in the United Kingdom

Fatema A Dehrab¹, Siara Teelucksingh¹, Antonio de Marvao¹, Renuka Murali Govind¹, Laura McCabe², Catherine Nelson-Piercy¹, Anita Banerjee¹

¹Department of Obstetric Medicine, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom

²Women’s Services, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom

Abstract

Background & Purpose: Pregnant women are at higher risk of developing severe COVID-19 compared with non-pregnant women, particularly in the third trimester¹. Despite ongoing campaigns, the proportion of pregnant women vaccinated against SARS-CoV-2 is lower than in the general population². The medium-term effects of COVID-19 during pregnancy are not well characterized. We report a cohort of pregnant women admitted to hospital with moderate-to-severe COVID-19.

Methods: Data from clinical records were retrospectively collected from all pregnant women admitted through the maternity assessment unit at St. Thomas’ Hospital, between January 2021 and January 2022, due to COVID-19 requiring oxygen to maintain saturations >94%.

Results: Fourteen women were identified (age=33.4±5.2 years; 42.8% Caucasian; 28.6% Black), requiring admission at 31±4.7 weeks gestation. Only two were double vaccinated (14.2%). Body mass index (BMI) was 27.2±6.4 kg/m2. Two women had concomitant co-morbidities (asthma and type 1 diabetes). They were managed in the obstetric high-dependency unit (level 1), barring one that required invasive ventilation for one day. The Delta variant was most commonly implicated (43%). All women requiring oxygen received steroids. Four women received Tocilizumab and three casirivimab/imdevimab; two received both. Four women were delivered by emergency Caesarean section due to maternal or fetal concerns, while the others continued their pregnancies. There was one late intrauterine death at 35 weeks. Women were followed-up for an average of six weeks. At follow-up in the obstetric medicine COVID-19 clinic, all women had complete resolution of COVID-19 on clinical examination, pulse oximetry and chest radiograph.

Conclusion: In 14 pregnant women requiring admission to hospital for hypoxia secondary to moderate-to-severe COVID-19, concomitant co-morbidities and high BMI were not prevalent. Most were not vaccinated against SARS-CoV-2. Despite experiencing moderate-to-severe COVID-19, they had complete clinical and radiological resolution at six weeks follow-up.

References

1. Nana M, Hodson K, Lucas N, Camporota L, Knight M, Nelson-Piercy C et al. Diagnosis and management of covid-19 in pregnancy BMJ 2022; 377 :e069739 doi:10.1136/bmj-2021-069739

2. Iacobucci G. Covid-19 and pregnancy: vaccine hesitancy and how to overcome it BMJ 2021; 375 :n2862 doi:10.1136/bmj.n2862

Post-Partum Maternal Bradycardia: A Case Series and Literature Review

Karen C. Tran, MD MHSc FRCPC¹, Cassandra D. Fayowski, MD FRCPC², Tessa Chaworth-Musters, MDFRCPC¹, Susan E Purkiss¹, Anthony Chau, MD FRCPC MMSc³, Matthew T. Bennett, MD FRCPC⁴ and Wee Shian Chang³

¹Division of General Internal Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada

²Department of Medicine, Western University, London, Ontario, Canada

³Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada

⁴Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada

Abstract

Background & Purpose: Unlike tachyarrhythmias, which are common in pregnancy, there is a paucity of data regarding maternal bradycardias. Maternal bradycardia has been associated with medications, neuraxial anesthesia, preeclampsia or underlying maternal cardiac conduction disease. The purpose of our study was to describe the characteristics, etiologies and prognosis of women who develop bradycardia post-partum.

Methods: We conducted a retrospective chart review of patients referred to the Obstetrical Medicine service at British Columbia Women’s Hospital from January 2012 to May 2020 for post-partum maternal bradycardia. Possible etiology of bradycardia was based on assessment of comorbid conditions, clinical course in hospital, investigations and follow up.

Results: Twenty-four patients with post-partum bradycardia were included (mean age 34.2±4.8 years; heart rate 40.4±8.1 beats per minute; mean blood pressure 131/72 mm Hg). The most common rhythm identified was sinus bradycardia (79.2%), followed by bigeminy/trigeminy (12.5%), Mobitz type I (4.2%), and first-degree heart block (4.2%). The most common symptom experienced was dyspnea (29.4%) followed by chest pain (23.5%). Fifteen women had transthoracic echocardiograms, of which only 2 were abnormal. Possible etiologies of bradycardia were preeclampsia (54.1%), pre-existing (16.7%), medications (12.5%), neuraxialanesthesia (8.3%), and underlying cardiac conduction and structural heart disease (4.2%). The mean time to resolution of bradycardia was 3.6 ±3.8 days.

Conclusion: Maternal bradycardia is an uncommon condition complicating post-partum period. The majority of post-partum maternal bradycardia is associated with preeclampsia. Maternal bradycardia is generally self-limited and the majority of patients only require clinical observation. Our study represents the largest case series describing the characteristics, concurrent maternal conditions and natural course of post-partum women with this presentation.

References

No references.

Postpartum Cardio-metabolic Clinics: Survey of Current Practices of North American Centres

Tabassum Firoz¹, Kara Nerenberg², Jay Parekh³ and Graeme N Smith⁴

¹Department of Medicine and Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine and Yale New Haven Health- Bridgeport Hospital, Bridgeport CT, USA

²Department of Medicine, Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary AB, Canada

³Department of Medicine, Yale New Haven Health- Bridgeport Hospital, Bridgeport CT, USA

⁴Department of Obstetrics and Gynecology, Kingston Health Sciences Centre, Queen's University, Kingston ON, Canada

Abstract

Background: Pregnancy complications such as hypertensive disorders of pregnancy (HDP) increase the risk of developing cardiovascular disease (CVD) later in life. Across Canada and the United States (US), dedicated postpartum maternal cardiometabolic clinics have emerged to address a gap preventative care by providing postpartum cardio-metabolic screening and evaluation.

Purpose: We aimed to understand the current practices of North American postpartum cardio-metabolic clinics including challenges faced.

Methods: Thirty centres were contacted via e-mail between October and December 2021 to complete an online survey. The survey contained sections on referrals, clinic structure, evaluation, management and challenges. Responses were analyzed descriptively.

Results: 20 centres completed the online survey, of which 12 (60%) were Canadian and 8 (40%) were US. All centres receive referrals from a variety of maternity care providers while some also receive referrals from medical specialists and primary care providers (PCP). All but one clinic in Canada were run by Obstetric Medicine whereas US clinics were mainly led by Maternal Fetal Medicine and nurse practitioners. Most sites offer both in person and virtual visits. All centres see women with HDP within 3 months of delivery but visit frequency vary across sites, ranging from a single visit to indefinite follow-up. Most centres perform cardio-metabolic screening between 3-6 months postpartum with variability in the types of investigations ordered and risk calculators used. All sites send a letter with recommendations to the PCP and 90% assist patients to find a PCP.Challenges identified by Canadian sites included insufficient resources particularly a need for multi-disciplinary teams. US sites identified funding, insurance coverage and buy in from obstetricians as challenges.

Conclusion: Current practices across North American postpartum cardio-metabolic clinics are varied. Clinics identified that guidelines, best practice statements and a collaborative network would be useful for management.

References

No references.

Prediction of Adverse Obstetrical Outcomes in Pregnant Patients with Sickle Cell Disease Based on Tricuspid Regurgitant Velocity – A Retrospective Cohort Study

Vincent Williams^1,2, Audrey Lacasse¹, Sergiu Vlad³, Natasha Nathoo^4,5, Sophie Grand’Maison^1,2,6, Bi Lan Wo^3,6,7, Véronique Cyr^1,8, Marie-Lou Tardif^1,9, Nadine Caron¹⁰, J. Viau-Lapointe^1,2,11, Véronique Naessens^4,12 and Michèle Mahone^1,2,6

¹Department of Medicine, Université de Montréal, Québec, Canada

²Division of Internal medicine, Centre Hospitalier de l’Université de Montréal, Québec, Canada

³Department Obstetrics and Gynecology, Université de Montréal, Québec, Canada

⁴Department of medicine, Université McGill, Québec, Canada

⁵Division of Internal medicine, Centre Universitaire de Santé McGill, Québec, Canada

⁶Centre de recherche de l’Université de Montréal, Québec, Canada.

⁷Department Obstetrics and Gynecology, Centre Hospitalier de l’Université de Montréal, Québec, Canada.

⁸Division of Cardiology, Centre Hospitalier de l’Université de Montréal, Québec, Canada

⁹Department Obstetrics and Gynecology, Hôpital Sainte-Justine, Québec, Canada

¹⁰Division of Internal medicine, Centre Hospitalier de l’Université de Sherbrooke, Québec, Canada

¹¹Division of Internal medicine, CIUSSS de l’Est-de-l’Île de Montréal, Québec, Canada

¹²Division of Hematology, Centre Universitaire de Santé McGill, Montréal, Canada

Abstract

Background & Purpose: Pulmonary hypertension (PH) is associated amongst patients with sickle cell disease (SCD) with a more severe course and increased mortality.¹ Transthoracic echocardiogram (TTE), although less accurate to diagnose PH than cardiac catheterisation², can identify higher-risk patients, as a tricuspid regurgitant velocity (TRV) over 2.5 m/s is associated with a higher mortality in the non-pregnant population.³The Royal College of Obstetricians and Gynaecologists recommends using TTE as a screening tool in the pregnant SCD population, but data are lacking.⁴ To our knowledge, only Soh et al.⁵ evaluated the prognostic value of TRV during pregnancy. However, this study included only 8 patients with a TRV over 2.5 m/s and was unable to demonstrate a significant difference in obstetrical and perinatal outcomes.

Methods: A multicenter retrospective cohort study aimed to assess the validity of TRV in pregnant women with SCD. The hypothesis was that an increase in maternal and fetal adverse outcomes in pregnant patients with TRV over 2.5 m/s would be observed.Data was collected on 88 pregnant women followed from 2003 to 2018 in five tertiary centers in Quebec, Canada, including 16 patients with a TRV over 2.5 m/s (“exposed group”).

Results: Primary maternal composite outcome included occurrence of severe vaso-occlusive crisis, acute chest syndrome, gestational hypertension, preeclampsia and mortality. These adverse events arose in both groups with no significant difference (50% in exposed group vs 67% in non-exposed group, P=0.334). Fetal primary composite outcome comprised perinatal mortality, premature delivery, reduced birth weight and fetal distress. Again, no significant difference was demonstrated (25% in exposed group vs 56% in non-exposed group, P=0.053).

Conclusion: Therefore, these preliminary results cannot support the use of a TRV > 2.5 m/s as a predictor of adverse maternal and fetal outcomes amongst pregnant patients with SCD.

References

1. Ataga KI, Moore CG, Jones S, et al. Pulmonary hypertension in patients with sickle cell disease: a longitudinal study. Br J Haematol 2006; 134(1): 109-15.

2. Parent F, Bachir D, Inamo J, et al. A hemodynamic study of pulmonary hypertension in sickle cell disease. New England Journal of Medicine 2011; 365(1): 44-53.

3. Cabrita IZ, Mohammed A, Layton M, et al. The association between tricuspid regurgitation velocity and 5-year survival in a North West London population of patients with sickle cell disease in the United Kingdom. Br J Haematol 2013; 162(3): 400-8.

4. Howard J, Oteng-Ntim E. The obstetric management of sickle cell disease. Best Pract Res Clin Obstet Gynaecol 2012; 26(1): 25-36.

5. Soh MC, Sankaran S, Chung NY, et al. Mildly raised tricuspid regurgitant velocity 2.5-3.0 m/s in pregnant women with sickle cell disease is not associated with poor obstetric outcome - An observational cross-sectional study. Obstet Med 2016; 9(4): 160-3.

Prevention of VTE in Pregnant Women with Cardiac Disease: A Retrospective Review of the Efficacy and Safety of Low Molecular Weight Heparin Thromboprophylaxis in Johannesburg, South Africa

Jarrod Zamparini¹, Elise Schapkaitz², Haroun Rhemtula³ and Annika Gerber³

¹Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa

²Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa

³Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa

Abstract

Background & Purpose: In South Africa, venous thromboembolism (VTE) is the eighth most common cause of maternal mortality, with 54.1% of these deaths deemed avoidable by the National Committee for Confidential Enquiries into Maternal Deaths.¹ Cardiac disease, including heart failure, is a recognised risk factor for VTE in pregnancy, necessitating thromboprophylaxis.²

Methods: We conducted a record review of pregnant women receiving enoxaparin thromboprophylaxis (excluding those with mechanical heart valves) at the Cardio-Obstetric and Haematology Clinic at Charlotte Maxeke Johannesburg Academic Hospital, South Africa over a five-year period. Study outcomes included objectively confirmed VTE, major bleeding, clinically relevant non-major bleeding (CRNMB) and minor bleeding. Approval was granted by the Wits Human Research Ethics Committee (Medical) (Certificate:M-220207).

Results: We identified 57 women of African ethnicity with a mean age of 32±6 years. Nine women (17.3%) were living with HIV, of which 6 (67%) had an undetectable viral load. Indications for thromboprophylaxis included: cardiomyopathies & heart failure (n=36), pulmonary arterial hypertension (n=7), valvular heart disease (n=10), congenital heart disease (n=2), arrhythmia (n=6) and chronic hypertension with multiple risk factors (n=5).Antepartum, clinical monitoring was performed in 2 women (4%), fixed low-dose enoxaparin was started in 45 (79%) at 23±9 weeks’ gestation and oral anticoagulation converted to therapeutic enoxaparin at 12±5 weeks’ gestation in 10 (18%). All women received enoxaparin prophylaxis until 5±2 weeks’ postpartum. There were 46 (89%) live births and 5 women (9%) were lost to follow-up. No VTE events occurred. There were 5 (10%, 95%CI; 0.2 to 0.4) primary postpartum bleeding events; four major bleeding events and one CRNMB. No women required transfusion.

Conclusion: Enoxaparin thromboprophylaxis in pregnant women with cardiac disease, whilst efficacious, was associated with significant risk of postpartum major bleeding, similar to international cohorts.^3–5 The high rate of PPH highlights the need for postpartum surveillance in a specialist centre.

References

1. National Committee on the Confidential Enquiries into Maternal Deaths. Saving Mothers 2017-2019: Seventh triennial report on confidential enquiries into maternal deaths in South Africa. Department of Health; 2020.

2. Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Royal College of Obstetricians and Gynaecologists Green-Top Guideline No. 37a [Internet]. Royal College of Obstetricians and Gynaecologists; 2015 [cited 2022 May 31]. Available from: https://www.rcog.org.uk/media/qejfhcaj/gtg-37a.pdf

3. Roeters Van Lennep JE, Meijer E, Klumper FJCM, Middeldorp JM, Bloemenkamp KWM, Middeldorp S. Prophylaxis with low-dose low-molecular-weight heparin during pregnancy and postpartum: is it effective? Journal of Thrombosis and Haemostasis. 2011;9(3):473–80.

4. Rajaratnam N, Patel JP, Roberts LN, Czuprynska J, Patel RK, Arya R. More on enoxaparin thromboprophylaxis in pregnancy: A review of 10 years’ experience from King’s College Hospital. Journal of Thrombosis and Haemostasis. 2021;19(1):304–8.

5. Cox S, Eslick R, McLintock C. Effectiveness and safety of thromboprophylaxis with enoxaparin for prevention of pregnancy-associated venous thromboembolism. Journal of Thrombosis and Haemostasis. 2019;17(7):1160–70.

Retrospective Study of Delayed Renal Recovery in HELLP Syndrome

Hamza Mahmood¹, Cassie Fayowski¹, Susan Huang² and Dongmei Sun¹

¹Department of Medicine, Schulich School of Medicine and Dentristy, Western University, London, Canada

²Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentristy, Western University, London, Canada

Abstract

Background: Hemolysis, elevated liver enzymes and thrombocytopenia (HELLP) syndrome is a severe, multi-system process occurring in 0.5-0.9% of pregnancies.¹ Acute kidney injury (AKI) has previously been described to affect 7-25% of cases of HELLP syndrome in older series.² The resulting complications from HELLP related AKI range from full renal recovery, to need for renal replacement therapy, to death.² Other studies show a wide variance in prevalence of AKI in HELLP, and the expected course of recovery.^3-5

It is unclear what the incidence and consequences of AKI in HELLP syndrome is in our institution. We sought to conduct a case series on patients at our institution with HELLP syndrome complicated by AKI.

Methods: This is a retrospective case series conducted at the London Health Sciences Centre and St. Joseph’s Health Care London, on all pregnancies with a diagnosis of HELLP from January 2001 to October 2020. Potential participants were identified using ICD-10 codes for preeclampsia and HELLP syndrome both from admission diagnosis and discharge diagnosis. In addition, investigator's case files were used. Charts were screened by two independent physicians. Data abstraction from patients’ hospital charts was done to identify cases as patients with HELLP syndrome with AKI, and then subdivided into rapid renal recovery (within 48 hours postpartum) or delayed renal recovery (beyond 48 hours postpartum). Descriptive statistics and graphs were used to describe the cohort.

Results: A total of 1862 charts were obtained for screening. Screening, data collection, and results are currently in progress.

References

1. Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management. A Review. BMC pregnancy and childbirth. 2009;9:8.

2. Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). American journal of obstetrics and gynecology. 1993;169(4):1000-6.

3. Novotny S, Lee-Plenty N, Wallace K, Kassahun-Yimer W, Jayaram A, Bofill JA, et al. Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome. Pregnancy Hypertens. 2020;19:94-9.

4. Ye W, Shu H, Yu Y, Li H, Chen L, Liu J, et al. Acute kidney injury in patients with HELLP syndrome. International urology and nephrology. 2019;51(7):1199-206.

5. Ye W, Shu H, Wen Y, Ye W, Li H, Qin Y, et al. Renal histopathology of prolonged acute kidney injury in HELLP syndrome: a case series and literature review. International urology and nephrology. 2019;51(6):987-94.

Review of the Indications and Complications of Intravenous Iron Therapy in the Intra-Partum and Postpartum Period at BC Women’s Hospital, Interim Analysis

Ellen Miles¹, Amanda Huynh², Helen Zhao³, Tessa Chaworth-Musters¹, Susan Purkiss¹ and Wee-Shian Chan

¹Division of Internal Medicine, BC Women's Hospital, University of British Columbia, Vancouver, Canada

²Division of Internal Medicine, McMaster University, Hamilton, Canada

³University of British Columbia, Vancouver, Canada

Abstract

Background & Purpose: Iron deficiency anemia affects one third of pregnancies and is a significant cause of morbidity. It is associated with maternal symptoms and adverse pregnancy outcomes, including preterm delivery and RBC transfusion. Firstline treatment is oral iron, however efficacy may be limited by malabsorption and GI intolerance. Second line treatment is IV iron, which is effective, but costly. Furthermore, access to IV iron is limited at our centre by the need for maternal and fetal monitoring.

Methods: Retrospective cohort study of 298 patients who received IV iron at BC Women’s Hospital between January 2017 and December 2019. Patients were included if they were age > 18 and received IV iron at our institution during the timeframe indicated. Data points collected included patient demographics, etiology of anemia, index hemoglobin and ferritin, timing of IV iron administration (antepartum or post-partum), symptoms, delivery outcomes, and adverse events during IV iron administration. Antepartum anemia was classified as mild (Hg 100-109 g/L), moderate (Hg 70-99 g/L) or severe (Hg < 70 g/L). Iron deficiency was classified as possible (Ferritin >30), probable (Ferritin 15-29) or definite (Ferritin < 15).

Results: 209 patients received IV iron antepartum and 87 received IV iron post-partum. The two most common etiologies of anemia were iron deficiency and post-partum hemorrhage. Most women were treated for moderate to severe anemia. The number of patients with moderate to severe anemia was significantly reduced in both the antepartum and post-partum period. Of 68 patients for whom safety data has been collected, there was 1 finding of fetal heart rate variable deceleration.

Conclusion: At BC Women’s hospital, IV iron is administered for moderate to severe anemia. Most women see a significant improvement in the severity of their anemia. Administration of IV iron is well tolerated by both mom and baby.

References

1. Organization WH. Intermittent iron and folic acid supplementation during pregnancy in malaria-endemic areas. World Health Organization. https://www.who.int/elena/titles/intermittent_iron_pregnancy_malaria/en/. Published 2019. Accessed June 20, 2019.

2. Daru J, Cooper NAM, Khan KS. Systematic review of randomized trials of the effect of iron supplementation on iron stores and oxygen carrying capacity in pregnancy. Acta Obstet Gynecol Scand. 2016;95(3):270-279. doi:10.1111/aogs.12812

3. World Health Organization. Haemoglobin Concentrations for the Diagnosis of Anaemia and Assessment of Severity. Miner Nutr Inf Syst World Heal Organ. 2013:1-6. doi:2011

4. American College of Obstetricians and Gynecologists Practice Bulletin no. 95: Anemia in Pregnancy. Am Coll Obstet Gynecol. 2009;112(101):11.

5. Daru J, Allotey J, Peña-Rosas JP, Khan KS. Serum ferritin thresholds for the diagnosis of iron deficiency in pregnancy: a systematic review. Transfus Med. 2017;27(3):167-174. doi:10.1111/tme.12408

6. Filippi, V., Chou, D., Ronsmans, C., Graham, W., Say L. Levels and causes of maternal mortality and morbidity. Reprod Matern Newborn, Child Heal Dis Control Priorities. 2016;3.

7. Muñoz M, Peña-Rosas JP, Robinson S, et al. Patient blood management in obstetrics: management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period: NATA consensus statement. Transfus Med. 2018;28(1):22-39. doi:10.1111/tme.1244

8. Pavord S, Myers B, Robinson S, Allard S, Strong J, Oppenheimer C. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol. 2012;156(5):588-600. doi:10.1111/j.1365-2141.2011.09012.x

9. Williamson HC. The use of blood transfusion in obstetrics and gynecology. Am J Obstet Gynecol. 1920;1(2):188-194. doi:10.1016/S0002-9378(20)90188-6

10. Auerbach M, Deloughery T. Single-dose intravenous iron for iron deficiency: A new paradigm. Hematology. 2016;2016(1):57-66. doi:10.1182/asheducation-2016.1.57

11. Myers, B., Myers, A., Moore J. Comparative efficacy and saffety of intravenous ferric carboxymaltose (Ferinject) and iron (III) hydroxide dextran (Cosmofer) in pregnancy. Obs Med. 2012;5:105-107.

12. Ayub, R., Tariq, N., Adil, MM., Iqbal, M., Junaid, A., Jaferry T. Efficacy and safety of total dose infusion of low molecular weight iron dextran in the treatment of iron deficiency anemia during pregnancy. J Coll Physicians Surg Pak. 2008;18(7):424-427.

13. Christoph, P., Schuller, C., Studer, H., Irion, O., De Tejada, BM., Surbek D. Intravenous iron treatment in pregnancy: comparison of high dose ferric carboxymaltose vs. iron sucrose. J Perinat Med. 2012;40(5):469-474.

14. Wong, L., Smith, S., Gilstrop M. Safety and efficacy of rapid (1,000mg in 1 hr) intravenous iron dextran for treatment of maternal iron deficient anemia of pregnancy. Am J Hematol. 2016;91(6):590-593.

Screening of Acylcarnitines of Mothers and Babies in Acute Fatty Liver of Pregnancy (SAMBA) Study

C Nelson-Piercy³, S Jarvis¹, RN Dalton², C Turner², PT Seed³, Y Rahman⁴, D Cregeen⁵ and MP Champion⁴

¹Imperial College Healthcare NHS Trust, Queen Charlottes & Chelsea Hospital, Du Cane Rd, London W12 0NN,

²WellChild Laboratory, Evelina London Children's Hospital, London SE1 7EH, UK

³Women's Health Academic Centre, Kings College London, St Thomas' Hospital, London SE1 7EH, UK

⁴Dept Paediatric Inherited Metabolic Medicine, Evelina London Children's Hospital, London SE1 7EH, UK

⁵Biochemical Genetics, Viapath, Guys Hospital, London SE1 9RT, UK

Abstract

Background: AFLP is a rare, life-threatening mitochondrial hepatopathy affecting 1:20,000 pregnancies¹. Although the pathogenesis is largely unknown, a link with fetal long-chain 3-hydroxyacyl coenzyme-A dehydrogenase (LCHAD) deficiency has been proposed for AFLP. The c.1528G>C p.(Glu510Gln) HADHA pathogenic variant has been reported in 19% of neonates from AFLP pregnancies and are also associated with HELLP syndrome ^2,3 Defective LCHAD leads to raised circulating acylcarnitines thus screening newborn acylcarnitines in babies from AFLP and HELLP pregnancies may identify cases. Maternal acylcarnitine levels (as mitochondrial dysfunction markers) in AFLP/HELLP have not been studied and may serve as biomarkers⁴

Purpose:

1. Prospectively define the incidence of newborn LCHAD in AFLP and HELLP pregnancies

2. Study maternal acylcarnitine levels in AFLP and HELLP syndrome and define normal ranges

Methods: This prospective study was carried out at Guy’s & St Thomas’ Hospital (2015-2020). Patients were included with a diagnosis of AFLP (using the Swansea criteria⁵) or HELLP syndrome. Tandem Mass Spectrometry (MS) API5000 was used to measure free carnitine, short, medium and long chain acylcarnitines from maternal plasma and newborn screening blood spot cards. Genetic analysis was undertaken on newborn blood spots to identify presence of the c1528G>C pathogenic variant in AFLP/HELLP (allele frequency 87% in LCHAD deficient patients⁶).

Results: 172 women were recruited (n=17 AFLP or HELLP syndrome, n= 155 low-risk controls). Firstly 2^nd and 3^rd trimester pregnancy-specific normal acylcarnitine ranges were defined. In AFLP (n=8), medium chain acylcarnitines C10:1 and C12 showed excellent discrimination from HELLP cases (n=5) (ROC values:0.90-0.96). Newborn acylcarnitines were normal and c.1528G>C HADHA gene variant was not detected.

Conclusion: In this prospective study, we did not identify newborn LCHAD suggesting the previously reported recurrent c.1528G>C variant is not prominent in our study population. We have identified a panel of elevated maternal acylcarnitines which may act as AFLP biomarkers requiring further validation.

References

1. Knight MC Nelson-Piercy, Kurinczuk JJ et al on behalf of UK Obstetric Surveillance System (UKOSS) (2008). A prospective national study of acute fatty liver of pregnancy in the UK. Gut 57: 951–956.

2. Yang Z, Yamada J, Zhao Y et al (2002) Prospective screening for pediatric mitochondrial trifunctional protein defects in pregnancies complicated by liver disease. JAMA. 288:2163-2166

3. den Boer ME, Ijlst L, Wijburg FA, et al (2000) Heterozygosity for the common LCHAD mutation (1528g>C) is not a major cause of HELLP syndrome and the prevalence of the mutation in the Dutch population is low. Pediatr Res;48:151-4.

4. McCann MR, George De la Rosa MV, et al (2021). L-Carnitine and Acylcarnitines: Mitochondrial Biomarkers for Precision Medicine. Metabolites. 14;11:51.

5. Ch’ng CL, Morgan M, Hainsworth I, et al (2002). Prospective study of liver dysfunction in pregnancy in Southwest Wales. Gut 51:876–80.

6. IJlst L, Ruiter JPN, Hoovers JMN et al (1996) Common missense mutation G1528C in long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency. J Clin Invest 98: 1028–1033.

Severe Hypercholanaemia Occurring at Later Gestational Weeks is Associated with Increased Stillbirth Risk in Intrahepatic Cholestasis of Pregnancy

Majewska Agata¹, Paul T. Seed¹, Chambers Jenny², Dixon H. Peter¹, Williamson Catherine¹ and Ovadia Caroline¹

¹Department of Women and Children’s Health/ King’s College London, London, United Kingdom

²Women’s Health Research Centre/ Imperial College London, London, United Kingdom

Abstract

Background & Purpose: Intrahepatic cholestasis of pregnancy (ICP) is a liver-specific disorder that has an incidence rate of 0.3–5.6%, with global variation. ICP is characterized by elevated maternal total serum bile acid (TSBA) concentrations (hypercholanaemia) and pruritus. Hypercholanaemia is a risk factor for perinatal complications including preterm birth and stillbirth. The TSBA threshold related to increased stillbirth risk is ≥ 100μmol/l. No other robust predictors have been demonstrated to identify pregnancies at risk of stillbirth. We aimed to evaluate whether gestational week at which bile acids were raised ≥100μmol/l was associated with stillbirth risk.

Methods: We performed an observational study, including pregnancies from 1995 to 2022 (198 singleton pregnancies) complicated by ICP with TSBA ≥100 μmol/l. Mann-Whitney tests and logistic regression were used to compare pregnancies with live and stillbirths at different gestational weeks using Stata17.0.

Results: Of the 198 pregnancies identified, 15 women had a stillbirth. The gestational age at which the peak TSBA ≥100 μmol/l was measured was significantly associated with stillbirth risk (odds ratio 1.28, 95% CI 1.06 to 1.56, p=0.013); women with stillbirths first developed severe ICP at a later gestation (p=0.029, ROC AUC 0.67, 95% CI 0.54 to 0.79). Furthermore, while 13 cases of stillbirth (86.67%) appeared in the subgroup with first TSBA concentrations ≥100 μmol/l measured at ≥ 28 weeks’ gestation, only 2 cases (13.33%) had first TSBA concentrations ≥100 μmol/l before 28 weeks, although this result was not significant (OR 3.47 (CI 0.77 – 15.74).

Conclusion: The gestational age when peak TSBA concentrations are ≥100 μmol/l impacts on stillbirth risk in severe ICP; women with a peak bile acid concentration above this threshold at later gestational weeks are at a higher risk. The mechanism undelying this risk may relate to decreased fetal tolerance of severely elevated bile acids after 28 weeks’ gestation.

Reference

1. Ovadia C, Seed PT, Sklavounos A, Geenes V, Di Ilio C, Chambers J, et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet. 2019;393(10174):899-909.

Severe Obesity: A Retrospective Cohort Study of Anaesthetic Practice in a Large UK Centre

K Murrell¹, M Wilson², K Wiles³ and P Verma⁴

¹Anaesthesia, Barts Health NHS Trust, London, United Kingdom

²Anaesthesia, North Central School of Anaesthesia, London, United Kingdom

³Obstetric Medicine, Barts Health NHS Trust, London, United Kingdom

⁴Anaesthesia, Barts Health NHS Trust, London, United Kingdom

Abstract

Background & Purpose: There is an increasing incidence of severe obesity (body mass index (BMI) >40kg/m²) in the obstetric population. This is associated with higher rates of anaesthetic complications. National guidance in the UK recommends antepartum anaesthetic review of pregnant persons with BMI>40kg/m² and the presence of a senior anaesthetist at operative delivery^1,2.

Method: This was a large, single-centre retrospective cohort study of all operative deliveries between May 2019 and January 2022. Demographic data, ante- and peri-partum anaesthetic involvement, and rates of major obstetric haemorrhage (>1500ml) were obtained from an obstetric anaesthetic database and electronic patient records. A senior anaesthetist was defined as an anaesthetist with more than five years of anaesthetic training. Complication rates in severely obese persons were compared to those with BMI <40kg/m² using a Chi-squared test.

Results: Data were available for 5,919 operative deliveries, including 125 patients with BMI >40kg/m². Anaesthetic review in advance of delivery was documented in 50% (63/125) of pregnancies. Operative deliveries in severely obese women were attended by a senior anaesthetist 78% (68/87) of the time. Severe obesity was associated with multiple attempts to site an epidural (38% versus 14%, p<0.0001). There was no measurable difference in rates of major obstetric haemorrhage in severely obese persons compared to those with BMI<40kg/m² (6% versus 8%, p=0.3)

Discussion: Severe obesity is found in 2% of pregnancies. Antepartum review does not take place for all severely obese pregnant persons. Although the majority of operative deliveries are attended by a senior anaethetist, a measurable increase in the number of attempts required to site an epidural persists. Interventions to improve the anaesthetic care of severely obese persons are required. Prospective data examining the value of senior out of hours staffing, specialist antepartum anaesthetic clinics and the use of ultrasound for regional anaesthesia are warranted.

References

1. Royal College of Anaesthetists, Chapter 9. Guidelines for the Provision of Anaesthesia Services (GPAS). Guidelines for the Provision of Anaesthesia Services for an Obstetric Population 2020.

2. Chereshneva M, Johnston C, Colvin JR and Peden CJ. Raising the Standards: RCoA quality improvement compendium. 7.2 Anaesthetic care for women who are obese during pregnancy. 4^th Edition. September 2020.

Simulation-Based Training in Obstetric Medical Emergencies for Junior Doctors

Yasmin Hazemi-Jebelli², Soomin Jang¹, Laura Harrington³, Nanci O'Reilly⁴ and Shaznin Visanji⁵

¹Foundation Year 1 Doctor. Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom

²Foundation Year 1 Doctor. Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom

³Acute Internal Medicine Registrar (ST5). Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom

⁴Acute Internal Medicine Registrar (IMT3). Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom

⁵Consultant in Acute Internal Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom

Abstract

Background & Purpose: Medical problems in pregnancy is a core part of the Internal Medicine Training (IMT) and General Internal Medicine (GIM) curriculum¹, and often an area that trainees feel underconfident in managing, especially medical emergencies. Simulation-based education is now recognised as an innovative method of interactive clinical teaching and training for healthcare professionals whilst allowing trainees to be exposed to high-risk scenarios with minimal risk to patient safety^2-4.

Methods: Junior doctors across the Trust were sent pre-simulation questionnaires assessing confidence (1-3 Likert scale) in managing pregnant patients that present with direct complications of pregnancy and those with pre-existing medical conditions. A one-day simulation day on medical emergencies in obstetric medicine was designed and implemented with scenarios including pulmonary embolism, acute kidney injury, asthma, seizure and cardiac arrest, representing common causes of deaths in pregnancy⁵. Trainees were given pre- and post-simulation questionnaires to compare confidence level in managing pregnant patients.

Results: We received 29 responses from a range of junior doctors. Seven reported receiving some training in managing pregnant patients, mostly in the form of lectures or during medical school. 100% of respondents said they would find a dedicated teaching programme in obstetric medicine with 18 trainees specified simulation to be the method of preference. On a scale of 1 to 3, 3 being confident and experienced, trainees scored an average of 1.52. Trainees reported lower confidence in managing patients with pre-existing conditions (1.41) compared with managing direct complications of pregnancy (1.81).

Conclusion: Postgraduate doctors lack confidence and experience in managing medical complications of pregnancy, this is especially in patients with pre-existing medical conditions. As a core part of the curriculum in IMT and higher speciality GIM training, simulation-based training in obstetric medicine can help improve confidence in managing medical emergencies in pregnancy.

References

1. Joint Royal Colleges Of Physicians Training Board. Curriculum for General Internal Medicine (Internal Medicine Stage 2) Training Implementation August 2022. 2022 May.

2. Lewis R, Strachan A, Smith MM. Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence. Open Nurs J 2012;6:82-89 – Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3415625/

3. Musits A, Wing R, Simoes M, Style M, Petrone G, Musisca N, Brown L. Interdepartmental Collaboration for Simulation-based Education: Obstetric Emergencies for Emergency Medicine. Rhode Island Medical Journal. 2020 May;(May):42–5.

4. Zendejas B, Brydges R, Wang AT, Cook DA. Patient Outcomes in Simulation-Based Medical Education: A Systematic Review. Journal of General Internal. 2013 Apr 18;28(8):1078–89.

5. Knight M, Bunch K, Tuffnell D, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ. MBRRACE-UK: Saving Lives, Improving Mothers’ Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-19. 2021 Nov.

The Incidence, Characteristics, Management and Outcomes of Symptomatic Peripartum Hyponatraemia in the UK: A Prospective, Descriptive Study Using the UK Obstetric Surveillance System (UKOSS)

A Pillai¹, N Lucas², Z Vowles³ and C Nelson-Piercy³

¹Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK

²Department of Anaesthesia, LNWH NHS University Trust, London, UK

³Department of Women and Children’s Health, Guy’s and St Thomas’s NHS Foundation Trust, UK/ Department of Women and Children’s Health, School of Life Course and Population Sciences, King’s College London, UK

Abstract

Background & Purpose: Peripartum hyponatraemia causing maternal and neonatal morbidity may be under-recognised.¹ There is limited evidence to guide management. This study aimed to determine the incidence, risk factors and outcomes of symptomatic peripartum hyponatraemia.

Methods: This was a national prospective observational study between April 2019 - September 2020 using UKOSS methodology.² The case definition was any woman with symptomatic hyponatraemia in labour or 48 hours following delivery where other likely causes have been clinically excluded.

Results: Sixty-three cases were reported with a maternal mean lowest [Na+] 118 mmol.l^-1. The commonest symptoms included confusion (33%), decreased consciousness (19%) and seizure (16%). Misdiagnosis of these symptoms was common. 40% of neonates were admitted to the neonatal unit and 41% of women needed critical care. 90% of women were primiparous and white. Median length of labour was 13:28 (hh:mm) . Median (IQR) BMI was 23kg.m^-2 (4.98).13% of women planned a home birth but only 2% delivered at home. 35% used a birthing pool in labour. 8% were treated with hypertonic saline (correction speed 1 mmol.hr^-1) but 73% were treated with fluid restriction alone (correction speed 0.63 mmol.hr^-1). Only 24% of women had oral intake recorded. 52% cases included an estimated oral intake – range 500 – 8000ml. 67% had iv fluid – range. 100 – 7115ml.

Conclusion: Symptomatic peripartum hyponatraemia is associated with significant maternal and neonatal morbidity. The calculated incidence is 5.79 per 100,000 deliveries. Misdiagnosis and self-resolution may mean this is an underestimate. There was an association with primiparous, white women, below UK average BMI, high fluid intake, longer labours, transfers of planned homebirths and use of a birthing pool during labour. Hypertonic saline was rarely used for management. Health professionals should be aware of the features of hyponatraemia and have access to rapid [Na⁺] testing. Maternal hyponatraemia should prompt neonatal testing even without severe maternal symptoms. Health professionals and women should be aware of the risks of excessive fluid intake. Improved recording of fluid intake in labour is needed.

References

1. Solomon N, Many A, Orbach R et al. Maternal and neonatal hyponatraemia during labor at term: a case series. J Matern Neonatal Med 2019;32 (16):2711-5

2. UK Obstetric Surveillance System. https://www.npeu.ox.ac.uk/ukoss#ukoss-a-national-system-to-study-rare-disorders-of-pregnancy. Accessed 4 June 2022.

The PreVASC Clinic: Can we Identify and Support High-Risk Post-Partum Patients in Cardiovascular Risk Reduction?

Kimberley M. Nix, MD¹, Irene W. Y. Ma, MD, PhD¹, Meghan Vlasschaert, MD^1,2, Kara Nerenberg, MD^1,2 and T.Lee-Ann Hawkins, MD^1,2

¹Division of General Internal Medicine, Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Canada

²Department of Obstetrics and Gynecology, University of Calgary, Calgary, Canada

Abstract

Background & Purpose: Hypertension Canada’s 2020 clinical practice guidelines emphasize the importance of education and cardiovascular risk reduction for patients after the hypertensive disorders of pregnancy (HDP). While 18 specialized clinics across Canada were developed to address this clinical need, they are limited by low rates of patient follow-up. Understanding the experiences and preferences of patients attending these clinics may help improve attendance and ultimately health outcomes. As such, this study’s objective was to examine the experiences of patients attending Calgary’s PreVASC clinic (which offers an initial consultation 3-6 months after delivery and annual follow-up for CVD risk factor screening and management) to inform CVD preventive care tailored for people after HDP.

Methods: This multi-method study was conducted in two stages: 1) quantitative electronic survey of patient experiences; and 2) individual semi-structured interviews conducted by phone. Eligible participants included patients who attended at least one clinic visit and consented to participate. Quantitative survey results were summarized with descriptive statistics and qualitative interviews were grouped thematically by two independent reviewers. Results were triangulated between the survey and interviews.

Results: 74 of 115 (64%) eligible patients consented and 57% (n=42) completed the electronicsurvey. Overall, 79% (n=33) of patients reported being “very satisfied” with the PreVASC clinic; 95% (n=40) reported making at least one health behavior change (e.g., heart-healthy diet or increasing physical activity); and 31% (n=23) reported a medication change. 11 participants completed interviews to achieve theme saturation which found improvements in health literacy and reductions in anxiety levels. Patients reported preferences for a specialty care provider and face-to-face visits despite the COVID-19 pandemic.

Conclusion: While patients reported high-satisfaction with an in-person model of CVD preventive care, additional research should examine the long-term impacts of clinical programs specifically tailored for people after HDP on patient-important health outcomes.

References

No references.

TRAIN-OBIM: Training Assessment in OB Internal Medicine

Colleen Foster¹ and Wee-Shian Chan¹

¹Department of Medicine, University of British Columbia, Vancouver, Canada

Abstract

Background & Purpose: General Internal Medicine (GIM) was recognized as a distinct subspecialty in 2010 with an additional 2 years of training during which one is expected to gain knowledge in obstetric medicine competencies^1,2. A survey from 2006, which polled graduates from Canadian universities over 10 years, revealed significant discrepancies between relevance and preparation for obstetric medicine³. After the implementation of a required one-month Obstetric Medicine (OBIM) rotation within GIM, we remain uncertain if this knowledge-practice gap is adequately addressed. We designed this project to determine if the one-month OBIM rotation at UBC was effective in preparing our Internists for practice.

Methods: A survey was sent to all UBC graduates who completed 4 years of Internal Medicine or the 5-year GIM program, from 2013 to 2020. Information about their pattern of practice, OBIM training and comfort level with specific obstetric medicine topics^4,5,6 were collected. Data analysis consisted of inferential testing via t-tests and descriptive statistics.

Results: Of the 52% of graduates who responded, 73% worked in secondary or community health care settings. More than half (59%) cared for pregnant patients. There was a statistically significant improvement in overall comfort level with OBIM between the 5 year vs the 4 year graduates; the former group had a compulsory one month OBIM rotation which the latter group did not. Of the topics assessed, respondents were most comfortable with venous thromboembolism, hypertensive disorders of pregnancy, abnormal liver enzymes and thrombocytopenia. 75% of respondents expressed interest in yearly OBIM review sessions.

Conclusion: Completion of a one-month OBIM rotation at our institution increased our graduates’ overall comfort level with OBIM compared to those who never completed the rotation. The most common OBIM cases encountered on rotation were the areas rated as greatest comfort by respondents. Finally, there appears to be strong interest amongst our respondents in continuing education in OBIM post-residency.

References

1. 2018 Royal College of Physicians and Surgeons of Canada. General Internal Medicine Competencies.

2. 2018 Royal College of Physicians and Surgeons of Canada. Internal Medicine Competencies.

3. Card S, Snell L, O’Brien B. Are Canadian General Internal Medicine training program graduates well prepared for their future careers? BMC Med Educ. 2006;6:56-65.

4. Cumyn, A et al. Defining competencies for training in obstetric medicine. Obstet Med. 2014;7(4):137-38.

5. Cumyn, A et al. Validation of a Canadian curriculum in Obstetric Medicine. Obstet Med 2010;3:145-51.

6. Magee, L et al. Obstetric medical care in Canada. Obstetric Medicine. 2016;9(3):117-19.