Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit

OBJECTIVE: To determine risk factors and outcomes for women with severe preeclampsia and renal failure. STUDY DESIGN: Retrospective study from 1995 to 1998 of all women with renal failure who were admitted to the obstetric intensive care unit at Groote Schuur Hospital, South Africa. A total of 89 women were identified with severe preeclampsia defined as blood pressure > or = 160/110 mm Hg and > or = 2+ proteinuria, renal failure defined as a creatinine level of > or = 1.13 mg/dL, and oliguria defined as < 100 mL urine produced in 4 hours; 72 charts were available for analysis. A comparison was made between the 3 groups, which were defined by the maximum recorded creatinine levels. RESULTS: Of the 72 women, 31 women (43%) were primiparous and 41 (57%) were multiparous. Median gestation at delivery was 32 weeks (range, 21-40 weeks). The median maximum creatinine was 3.85 mg/dL (range, 1.13-12.50 mg/dL). Twelve women (16%) had a history of chronic renal disease or hypertension, and 36 women (50%) had HELLP syndrome and 23 (32%) abruptio placentae. All women with severe renal impairment had either abruptio placentae or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Perinatal mortality was 38% (27/72). However, in this series only 7 women (10%) required dialysis in the short term and none required long-term dialysis or kidney transplant. There were no maternal deaths. CONCLUSIONS: In women with severe preeclampsia and renal failure, major obstetric complications were common and perinatal outcome was poor. However, the need for dialysis was infrequent, with only 10% women requiring transient dialysis, and there were no cases of chronic renal failure that required dialysis or kidney transplant.     

Obstetric outcomes of human immunodeficiency virus-1-serodiscordant couples following in vitro fertilization with intracytoplasmic sperm injection

The objective of this article is to report obstetric outcomes of human immunodeficiency virus-1 (HIV-1)-serodiscordant couples who underwent in vitro fertilization and embryo transfer (IVF-ET) with intracytoplasmic sperm injection (ICSI) at a tertiary care center. We reviewed the outcomes of seronegative women after IVF-ET with ICSI from January 1, 1997 to June 1, 2002. Serodiscordant couples (n = 25) successfully conceived 27 pregnancies delivering 40 neonates (16 singletons, 9 twins, and 2 triplets). The mean gestational age at delivery was 37 0/7 weeks +/- 3 6/7 weeks (range 26 0/7 to 41 2/7 weeks). The mean birth weight was 2646 g +/- 952 g (range 678 to 4396 g). The cesarean section rate was 70%. Preterm delivery (<37 weeks) occurred in 7 pregnancies, and low birth weight (<2500 g) was observed in 8 pregnancies. There were no HIV-1 seroconversions detected at delivery. One hundred percent of the mothers and offspring were beyond 3 months postpartum and remained seronegative. IVF-ET with ICSI seems safe and effective for serodiscordant couples. Obstetric outcomes are favorable, and HIV-1 infection risk is limited.     

Pregnancy in women with renal disease. Part I: general principles

The purpose of this review is to improve the basis upon which advice on pregnancy is given to women with renal disease and to address issues of obstetric management by drawing upon the accumulated world experience. To ensure the proper rapport between the respect for patient's autonomy and the ethical principle of beneficence, the review attempts to impart up-to-date, evidence-based information on the predictable outcomes and hazards of pregnancy in women with chronic renal disease. The physiology of pregnancy from the perspective of the affected kidney will be discussed as well as the principal predictors of maternal and fetal outcomes and general recommendations of management. The available evidence supports the implication that the degree of renal function impairment is the major determinant for pregnancy outcome. In addition, the presence of hypertension further compounds the risks. On the contrary, the degree of proteinuria does not demonstrate a linear correlation with obstetric outcomes. Management and outcome of pregnancies occurring in women on dialysis and after renal transplant are also discussed. Although the outcome of pregnancies under chronic dialysis has markedly improved in the past decade, the chances of achieving a viable pregnancy are much higher after transplantation. But even in renal transplant recipients, the rate of maternal and fetal complications remains high, in addition to concerns regarding possible adverse effects of immunosuppressive drugs on the developing embryo and fetus.     

Increased risk in the elderly parturient

PURPOSE OF REVIEW: The steady increase in age in primiparous and multiparous women raises questions concerning increased obstetric risk and outcome in such pregnancies. This review highlights the effects of maternal age on obstetric and perinatal outcome. RECENT FINDINGS: Complications have been associated with increasing maternal age, including abnormal weight gain, obesity, gestational diabetes, chronic and pregnancy-induced hypertension, antepartum haemorrhage, placenta praevia, multiple gestation, prelabour rupture of membranes, and preterm labour. Intrapartum complications of malpresentation, fetopelvic disproportion, abnormal labour, increased use of oxytocin in labour, caesarean section, instrumental delivery, sphincter rupture, and postpartum haemorrhage are more frequent in older women. Advanced maternal age is associated with a higher risk of stillbirth throughout gestation, and the peak risk period is 37-41 weeks. Perinatal outcomes differ with maternal age concerning gestational age, birth weight, prematurity, low birth weight, incidence of small-for-gestational-age infants, fetal distress, and perinatal morbidity and mortality. The increased risk cannot be explained only by intercurrent illness or pregnancy complications. SUMMARY: Increasing maternal age is independently associated with specific adverse outcomes. Increasing age is a continuum rather than threshold effect. More information about obstetric consequences of delayed childbearing is needed both for obstetricians and fertile women.     

Prediction of intra-twin birth weight discordance by binary logistic regression analysis

AIMS: Identification of women at high risk of intra-twin birth weight discordance is helpful in obstetric care of these pregnancies. The aim of this study is to establish an intra-twin birth weight discordance prediction model. METHODS: We created an intra-twin birth weight discordance prediction model by logistic regression, based on the 1995-1997 register twin birth data of the USA. The twin sets were randomly divided into two groups: group 1 to establish the prediction model and group 2 to validate the prediction model. Intra-twin birth weight discordance was defined as birth weight discordance > 25%. The prediction model was validated by receiver operating characteristic curve. RESULTS: A birth weight discordance prediction model including maternal age (beta = 0.069), parity (beta = 0.250), fetal gender concordance (beta = 0.041), maternal hypertension (beta = 0.368), eclampsia (beta = 0.316), other medical complication (beta = 0.165), and smoking (beta = 0.164) was established, yielded a 0.558 area under the receiver operating characteristic curve. The sensitivity, specificity, and positive predictive values were 38.1, 69.7, and 10.8%, respectively, at the cut-off value of 0.09 in group 2. CONCLUSION: A birth weight discordance prediction model that includes seven variables available during pregnancy has been established with acceptable diagnostic performance.     

Obstetric outcomes in nulliparous women aged 35 and over with dichorionic twin pregnancy

The aim of this study is to investigate maternal and neonatal outcomes in dichorionic twins to nulliparous women older than 35 compared to those of their younger counterparts. This was a retrospective study of dichorionic twin pregnancies managed at Japanese Red Cross Katsushika Maternity Hospital between 2002 and 2006. Nulliparous women 35 years and older at delivery (n = 60) were compared with nulliparous women between the ages of 20 and 29 at delivery (n = 71). The women ≥ 35 year old were more likely to have used assisted reproductive technology. There were no measurable differences in obstetric outcomes such as preeclampsia, premature delivery, low birth weight and neonatal asphyxia between the two pregnancies. Advanced maternal age does not seem to affect obstetric outcomes in nulliparous dichorionic twin pregnancies.     

Pregnancy outcome in renal transplant recipients

Objective: To correlate pregnancy outcome with complications in pregnancy and transplantation-to-pregnancy interval in renal transplant recipients in Croatia. Method: Data on 23 pregnancies after prepregnancy stabilization of blood pressure and normalization of graft function were retrospectively analyzed. Result: The mean interval between transplantation and conception was 3.1 years. Primary renal disease was chronic glomerulonephritis in 7, chronic pyelonephritis in 7 and agenesis of right kidney and stenosis of left renal artery in 1 patient. There were 10 term and 5 preterm deliveries, 6 induced and 2 spontaneous abortions. The mean gestational age was 38.1 weeks and the mean newborn birthweight was 3015 g. The prematurity rate was 21.7%. Patients with arterial hypertension in pregnancy, elevated serum creatinine level and bacteriuria, as well as those with conception occurring less than 2 years after transplantation, had a higher rate of therapeutic and spontaneous abortions, preterm deliveries and low birth weight infants. Conclusion: The interval between transplantation and conception, as well as allograft function during pregnancy, seem to be of great importance for successful obstetric outcome in renal transplant patients.     

Inherited thrombophilia: treatment during pregnancy

OBJECTIVE: Inherited thrombophilia is associated with thromboembolic events and/or poor obstetric outcome. We evaluated the pregnancy outcome in women with inherited thrombophilia treated with low-molecular-weight heparin (LMWH). METHODS: 38 thrombophilic women with a history of thromboembolic events and/or poor obstetric outcome were treated during their 39 consecutive pregnancies with LMWH from pregnancy verification until 4-6 weeks in puerperium. A fixed dose of enoxaparin 4,000 IU/day (except 1 case who required nadroparin 0.3 ml/day) was administered in most cases, adopting a higher dose (6,000 IU/day to 6,000 IU twice a day) in those with previous thromboembolic events. RESULTS: In the treated women, all had a good obstetric outcome, whereas in the previous untreated pregnancies (n = 78), the rate of fetal loss (early and late) was 76.9%, only 12 live infants survived (66.6%). Moreover, birth weight resulted significantly higher in live infants born to treated pregnancies in comparison to that of previous untreated pregnancies (p = 0.009). No maternal thrombosis or major bleeding complications were recorded. CONCLUSIONS: The treatment with LMWH improved pregnancy outcome resulting effective and safe in thrombophilic women with a history of thromboembolic events and/or poor obstetric outcome.     

Pregnancy outcome after stillbirth

OBJECTIVE: To assess the subsequent pregnancy outcome in women with previous stillbirth. STUDY DESIGN: The study included all women (n = 54) who delivered a stillbirth between 1997 and 2001 in our department. A control group of women with live birth (n = 108) was matched for delivery within the same year, maternal age (+/- 3 years), parity (+/- 1) and gestational age at delivery (+/- 2 weeks). On February 1, 2004, the charts of these women were examined for subsequent pregnancies. RESULTS: Similar subsequent pregnancy rates were found in women with previous stillbirth and live birth (61.1% and 54.6%), respectively. There were no recurrences of stillbirth; gestational age at delivery, birth weight and Apgar score at 5 minutes were similar to those in the control group, and there was no statistically significant increase in abortion, induction or cesarean section rates. CONCLUSION: There is a favorable outcome in pregnancy following stillbirth. This information is useful for prepregnancy counseling of parents with previous stillbirth.     

Outcome of pregnancy in renal allograft recipients

Objective  To evaluate risk factors affecting pregnancy, perinatal outcomes and graft condition in women who underwent renal transplantation. Methods  Retrospective study of 34 pregnancies in 28 renal recipients followed in a single tertiary center from January 1989 to January 2007. Main outcome measures  Pregnancy outcome, kidney allograft function, maternal complications and perinatal outcomes were evaluated in these patients. Results  Mean maternal age at time of pregnancy was 27 ± 5.1 years (18–37) and the interval between transplant and pregnancy varied between 1 and 134 months (mean 51.3 ± 34.2). Most pregnant women (25/28) were submitted to triple immunosuppression during the entire pregnancy. The fetal outcome included 27 live births (79.4%), 2 stillbirths (5.9%), 3 spontaneous abortions (8.8%) and 2 therapeutic abortions (5.9%). The most frequent maternal complications were hypertension in 18 pregnancies, 2 of which ended in pre-eclampsia; urinary tract infections in 10 pregnancies; gestational diabetes mellitus in 3, anemia in 3 and 2 acute graft rejections. The major fetal complications observed consisted of four (13. 8%) intrauterine growth restrictions and two (6.9%) stillbirths. Vaginal delivery occurred in 10 women (34.5%); in the other 19 (65.5%), a cesarean section was performed. Of the 27 successful pregnancies, 11 (40.7%) resulted in term deliveries and 16 (59.3%) in preterm deliveries (range 31–39 weeks). The mean birth weight of the offspring was 2,465 g (range 1,300–3,530). There were no major perinatal complications, but two allograft rejections occurred after pregnancy. Conclusions  This series results are in agreement with those in other studies. Even though pregnancy does not seem to adversely affect short-term renal allograft function, risks of obstetric and perinatal complications seem to be increased. Further studies of long term graft function and pediatric follow-up are needed.     

Pregnancy in patients on chronic dialysis: a single center experience and combined analysis of reported results

OBJECTIVE(S): Pregnancy is rare in patients on chronic dialysis, with only a 30-50% rate of successful delivery reported in a previous review article. The pregnancy outcome has improved in recent decades, but data on pregnancy outcome are limited due to the small sample size of previous case series. This study investigated the pregnancy outcome in patients on chronic dialysis over the past 15 years in a single center, and also performed a combined analysis of results of individual cases from previously reported series to obtain overall estimates of rates of successful delivery. STUDY DESIGN: Medical records for a total of 13 pregnancies in 13 women undergoing chronic dialysis (10 on hemodialysis and 3 on peritoneal dialysis) during the period from 1990 to 2006 in our hospital were retrospectively reviewed. Data on the changes in dialysis regimen, medical complications, obstetric conditions, and perinatal problems were collected. An electronic search of PubMed identified 10 case series studies and 12 case reports published after 1990 with adequate individual information available. Pooled data from a total of 131 cases, including our patients (117 hemodialysis and 14 peritoneal dialysis), were analyzed using the chi(2)-test and the t-test to compare the rate of successful delivery and birth weight in the hemodialysis group and the peritoneal dialysis group, and in pregnancies with conception prior to and those with conception after starting dialysis. RESULTS: Among the 10 pregnant women who decided to continue their pregnancies in our hospital, 5 delivered live newborns and 5 pregnancies ended with intra-uterine fetal demise or neonatal death. The overall rate of successful delivery was 70.9% (83 out of 117) in patients on hemodialysis and 64.2% (9/14) in patients on peritoneal dialysis. The birth weight for these groups was 1483+/-116 and 1623+/-320 g, respectively. The difference in the rates of successful delivery in these two groups was not significant (p=0.61). However, the birth weight was significantly greater in patients who conceived after than those who conceived prior to starting hemodialysis (1529+/-132 g versus 1245+/-200 g; p=0.04). CONCLUSIONS: This study found that the outcome of pregnancy on chronic dialysis has improved in recent decades, but our study showed no significant difference in the rate of successful delivery between patients on hemodialysis and those on peritoneal dialysis.     

Postpartum stroke: a twenty-year experience

OBJECTIVE: The aim of this study was to characterize the clinical presentation, etiology, and acute and subsequent outcomes of postpartum stroke. STUDY DESIGN: This 20-year, single-center, retrospective review included 20 women without previous neurologic deficit with clinical and neuroimaging diagnoses of postpartum stroke. RESULTS: Eight of 20 women (40%) were delivered abdominally. Conduction anesthesia was induced in 9 of 20 women (45%). Causes of stroke included cerebral infarction (n = 13; 7 venous, 6 arterial), intracerebral hemorrhage (n = 5; 1 cocaine-induced, 1 anatomic malformation), cerebritis (n = 1), and cerebral atrophy (n = 1). The median time at onset of stroke was 8 days post partum (range, 3-35 days). Headache, seizures, visual change, and hemiparesis were the most common presenting findings but were neither specific to the underlying pathologic condition nor predictive of ultimate maternal outcome. There were 2 maternal deaths, both caused by severe intracerebral hemorrhage. Intracerebral hemorrhage was associated with the poorest outcome (2 deaths and 1 residual neurologic deficit). Eight women had residual neurologic deficit. There was no correlation between a trial of labor (P =.4; odds ratio, 0.4; 95% confidence interval, 0.01-6.5) or vaginal versus cesarean mode of delivery (P =.6; odds ratio, 1.3; 95% confidence interval 0.1-16.8) and ultimate neurologic diagnosis (cerebral infarction or intracerebral hemorrhage). However, the incidence of cesarean delivery was greater in the cohort of women with postpartum stroke than in the overall obstetric population (P =.015; odds ratio, 3.2; 95% confidence interval, 1.2-8.5). One of the 20 women received methergine; 1 received bromocriptine. All women were either normotensive or had well-controlled hypertension at postpartum discharge. New-onset hypertension or exacerbation of existing hypertension occurred after the acute neurologic insult; subsequent mean (+/-SD) arterial blood pressure was 128.9 +/- 24.0 mm Hg. CONCLUSION: Postpartum stroke is a multifactorial, uncommon, and nonpreventable complication of pregnancy. There was an association between postpartum stroke and hypertensive disorders of pregnancy and cesarean delivery. However, this study refutes any etiologic association between conduction anesthesia and postpartum stroke.     

Low maternal concentrations of soluble vascular endothelial growth factor receptor-2 in preeclampsia and small for gestational age.

OBJECTIVES: Preeclampsia is considered an anti-angiogenic state. A role for the anti-angiogenic factors soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) and soluble endoglin in preeclampsia has been proposed. Soluble vascular endothelial growth factor receptor-2 (sVEGFR-2) has been detected in human plasma, and the recombinant form of this protein has anti-angiogenic activity. There is a paucity of information about maternal plasma sVEGFR-2 concentrations in patients with preeclampsia and those without preeclampsia with small for gestational age (SGA) fetuses. This study was conducted to determine whether: (1) plasma sVEGFR-2 concentration changes throughout pregnancy; and (2) preeclampsia and SGA are associated with abnormalities in the maternal plasma concentration of sVEGFR-2. STUDY DESIGN: This cross-sectional study included non-pregnant women (n = 40), women with normal pregnancies (n = 135), women with an SGA fetus (n = 53), and women with preeclampsia (n = 112). SGA was defined as an ultrasound-estimated fetal weight below the 10(th) percentile for gestational age that was confirmed by neonatal birth weight. Plasma concentrations of sVEGFR-2 were determined by ELISA. RESULTS: (1) There was no significant difference in the mean plasma concentration of sVEGFR-2 between non-pregnant women and those with normal pregnancies (p = 0.8); (2) patients with preeclampsia and those without preeclampsia with SGA fetuses had a lower mean plasma concentration of sVEGFR-2 than that of women with normal pregnancies (p < 0.001 for both); and (3) there was no significant difference in the mean plasma concentration of sVEGFR-2 between patients with preeclampsia and those without preeclampsia with SGA (p = 0.9). CONCLUSIONS: Preeclampsia and SGA are associated with low plasma concentrations of sVEGFR-2. One interpretation of the findings is that plasma sVEGFR-2 concentration could reflect endothelial cell function.     

Obstetric outcome in post-term pregnancies: time for reappraisal in clinical management

BACKGROUND: The objective of this study was to determine the outcome of pregnancy in post-term cases compared with term cases in a well defined population receiving modern obstetric care. METHODS: We utilized the population-based birth registry data of the Kuopio University Hospital (1990-2000) to investigate pregnancy outcome in 1,678 post-term singleton pregnancies. The general obstetric population (n=22,712) was used as a reference group in logistic regression analysis. RESULTS: The overall frequency of post-term pregnancies was 6.9% and the incidence of post-term pregnancies was found to be increased in obese, primiparous, and smoking women, whereas in women with chronic diseases and obstetric risks deliveries were induced earlier. The risks of macrosomia, maternal complications, and operative deliveries were increased in post-term pregnancies. Post-term infants experienced meconium passage (21.2% versus 12.8%) (p<0.01) and intrapartum asphyxia (3.4% versus 2.1%) (p<0.01) significantly more often than the controls. However, the stillbirth rate was low, probably due to careful monitoring of these pregnancies. CONCLUSIONS: Although high-risk pregnancies were not allowed to come post-term, postmaturity per se is a moderate risk state compromising fetal well-being with regard to meconium passage and acid-base status at birth. We conclude that simple antenatal monitoring beyond 42 weeks reduces perinatal mortality but is inefficient in reducing meconium-stained liquor seen with increasing gestation.     

Infant and Maternal Outcomes for Women Who Experience Imprisonment in Ontario,Canada: A Retrospective Cohort Study

ObjectiveTo describe the population-level risk of infant and maternal outcomes for women who experience imprisonment and compare outcomes with the general population.MethodsWe conducted a retrospective cohort study. We used linked correctional and health data for women released from provincial prisons in 2010. We defined three exposure groups for Ontario singleton deliveries from 2005-2015: deliveries to women who were in prison during pregnancy but not necessarily for delivery, prison pregnancies; deliveries to women who had been in prison but not while pregnant, prison controls; and general population deliveries. We compared groups using generalized estimating equations. Primary outcomes were preterm birth, low birth weight, and small for gestational age birth weight. Secondary outcomes included NICU admission, neonatal abstinence syndrome, placental abruption, and preterm prelabour rupture of membranes.ResultsIn prison pregnancies (n = 544) and prison controls (n = 2156), respectively, preterm birth risk was 15.5% and 12.5%, low birth weight risk was 13.0% and 11.6%, and small for gestational age birth weight risk was 18.1% and 19.2%. Adjusted for maternal age and parity and compared with general population deliveries (N = 1 284 949), odds ratios were increased for prison pregnancies and prison controls, respectively, at 2.7 (95% CI 2.2–3.4) and 2.1 (95% CI 1.9–2.4) for preterm birth, 3.1 (95% CI 2.4–3.9) and 2.7 (95% CI 2.3–3.1) for low birth weight, and 1.6 (95% CI 1.3–2.1) and 1.8 (95% CI 1.6–2.0) for small for gestational age birth weight.ConclusionThere is an increased risk of adverse infant outcomes in women who experience imprisonment compared with the general population, whether they are in prison during pregnancy or not.     

Maternal morbidity and obstetric complications in triplet pregnancies and quadruplet and higher-order multiple pregnancies

OBJECTIVE: The purpose of this study was to assess the risk of maternal morbidity and obstetric complications in women with triplet pregnancies and quadruplet and higher-order multiple pregnancies. STUDY DESIGN: We compared the outcomes in women with triplet pregnancies (n=5491) and quadruplet and higher-order multiple pregnancies (n=423) with women with twin pregnancies (n=152,238), with the use of the 1995 to 1997 Multiple Birth File of the United States. RESULTS: After an adjustment was made for important confounding factors, the risks of pregnancy-associated hypertension and eclampsia, anemia, diabetes mellitus, abruptio placenta, premature rupture of membrane, and cesarean delivery were increased in women with triplet pregnancies and quadruplet and higher-order multiple gestations than in women with twin pregnancies. A dose-response relationship was observed for pregnancy-associated hypertension, diabetes mellitus, and placental abruption, with higher odds ratios in women with quadruplet and higher-order multiple gestations than in women with triplet pregnancies. CONCLUSION: The risks of maternal morbidity and obstetric complications are increased in triplet pregnancies and quadruplet and higher-order multiple pregnancies than in twin pregnancies; for certain outcomes, there is a dose-response relationship.     

Maternal and perinatal outcome in nulliparous women aged 35 and older

OBJECTIVE: To compare the maternal and perinatal outcome of nulliparous women 35 years and older at the time of delivery with nulliparous women 25-29 years old. METHODS: A retrospective review of maternal and newborn records of singleton gestations only for first birth in women aged 35 and older (study group n = 143) were compared with pregnancies of women aged 25-29 (control group, n = 148) delivered at the same period with respect to pregnancy complications and outcome. The study was performed at the Princess Badeea Teaching Hospital in North Jordan between January 1, 1996 and July 1, 2000. RESULTS: Most of the elderly nulliparous women were professionals (60%) and 20% had a history of infertility. Compared with women aged 20-29 years, women delivering their first child at or >35 years were at increased risk of weight gain, obesity, chronic and pregnancy-induced hypertension, antepartum haemorrhage, multiple gestation, malpresentation, and premature rupture of membranes. Women aged 35 years and older were also substantially more likely to have preterm labour, oxytocin use, and caesarean births. The older women differed significantly in neonatal outcomes: gestational age, birth weight, preterm delivery, low birth weight, small for gestational age, fetal distress and neonatal intensive care unit admissions. CONCLUSION: It is concluded that nulliparous women 35 years and older had higher risk of antepartum, intrapartum, and neonatal complications than nulliparous women aged 25-29 years, but these risks, for the most part, are manageable in the context of modern obstetrics. The excess rate of caesarean sections is only partially accounted for by gestational complications. Despite the increased risk of complications, perinatal death of the study group was similar to that of the control group. There were no maternal deaths.     

Pregnancy in patients on chronic dialysis: A single center experience and combined analysis of reported results

Objective(s)

Pregnancy is rare in patients on chronic dialysis, with only a 30–50% rate of successful delivery reported in a previous review article. The pregnancy outcome has improved in recent decades, but data on pregnancy outcome are limited due to the small sample size of previous case series. This study investigated the pregnancy outcome in patients on chronic dialysis over the past 15 years in a single center, and also performed a combined analysis of results of individual cases from previously reported series to obtain overall estimates of rates of successful delivery.

Study design

Medical records for a total of 13 pregnancies in 13 women undergoing chronic dialysis (10 on hemodialysis and 3 on peritoneal dialysis) during the period from 1990 to 2006 in our hospital were retrospectively reviewed. Data on the changes in dialysis regimen, medical complications, obstetric conditions, and perinatal problems were collected. An electronic search of PubMed identified 10 case series studies and 12 case reports published after 1990 with adequate individual information available. Pooled data from a total of 131 cases, including our patients (117 hemodialysis and 14 peritoneal dialysis), were analyzed using the χ²-test and the t-test to compare the rate of successful delivery and birth weight in the hemodialysis group and the peritoneal dialysis group, and in pregnancies with conception prior to and those with conception after starting dialysis.

Results

Among the 10 pregnant women who decided to continue their pregnancies in our hospital, 5 delivered live newborns and 5 pregnancies ended with intra-uterine fetal demise or neonatal death. The overall rate of successful delivery was 70.9% (83 out of 117) in patients on hemodialysis and 64.2% (9/14) in patients on peritoneal dialysis. The birth weight for these groups was 1483 ± 116 and 1623 ± 320 g, respectively. The difference in the rates of successful delivery in these two groups was not significant (p = 0.61). However, the birth weight was significantly greater in patients who conceived after than those who conceived prior to starting hemodialysis (1529 ± 132 g versus 1245 ± 200 g; p = 0.04).

Conclusions

This study found that the outcome of pregnancy on chronic dialysis has improved in recent decades, but our study showed no significant difference in the rate of successful delivery between patients on hemodialysis and those on peritoneal dialysis.     

孕期及产后妇女发生尿失禁的影响因素

目的 探讨不同分娩方式对孕产妇发生尿失禁的影响和阴道分娩后发生产后压力性尿失禁(SUI)的相关因素.方法 选择2008年1-12月在首都医科大学附属北京妇产医院行产前检查并于分娩后6～8周复查的孕产妇788例.根据分娩方式不同分为剖宫产组212例、阴道顺产组534例、产钳助产组42例,将阴道顺产组和产钳助产组孕产妇合计后统计尿失禁发生情况.采用问卷调查方式了解各组孕产妇分娩方式及其与分娩有关的产科因素对产后SUI发生的影响.并使用盆底肌电图检测各组孕产妇盆底肌强度,了解产后SUI发生与盆底肌肉强度的关系.结果 (1)尿失禁发生率:孕期尿失禁总的发生率为15.4%(121/788),其中阴道顺产组为15.9%(85/534),产钳助产组为11.9%(5/42),剖宫产组为14.6%(31/212),3组比较,差异无统计学意义(P>0.05).产后6～8周SUI总的发生率为17.1%(135/788),其中阴道顺产组为19.1%(102/534),产钳助产组为26.2%(11/42),剖宫产组为10.4%(22/212).阴道顺产组产后SUI发生率明显低于产钳助产组,两组比较,差异有统计学意义(P<0.01);剖宫产组产后SUI发生率明显低于阴道顺产组,两组比较,差异有统计学意义(P<0.01).(2)不同产科因素对产后SUI的影响:阴道顺产组和产钳助产组孕产妇共发生尿失禁113例,未发生尿失禁463例,将尿失禁发生与否两类孕产妇的一般情况和产科因素进行单因素分析和logistic多元回归分析,了解其对产后SUI的影响.结果显示,分娩方式、新生儿出生体质量、孕期发生尿失禁是产后SUI的主要影响因素.剖宫产术可使产后SUI发病率降低(P<0.01),新生儿出生体质量增加、孕期发生尿失禁可使产后SUI的发生风险加大.对阴道分娩组和产钳助产组孕产妇分析发现,新生儿出生体质量增加、产钳助产、孕期发生尿失禁与产后SUI发病率升高有关(P均<0.01);而与分娩镇痛、产程时间、会阴侧切、产后哺乳、产后出血量、分娩孕周、引产与否、孕前体质量等无明显相关(P均>0.05).(3)盆底肌电图检测结果:剖宫产组孕产妇盆底肌活力值为(19.7±9.9)μv,做功值为(84.5±37.2)μv,峰值为(25.5±12.5)μv,均高于阴道顺产组和产钳助产组[两组均值为:活力值(14.8±8.4)μv、做功值(78.8±28.2)μv、峰值(19.7±11.8)μv].两者比较,差异有统计学意义(P均<0.01).阴道顺产组和产钳助产组中尿失禁孕产妇盆底肌放松值[均值为(1.7±1.8)μv]较非尿失禁孕产妇[均值为(3.0±3.9)μv]低,两者比较,差异有统计学意义(P<0.01).尿失禁孕产妇放松值与活力值(r/a)比值为0.2±0.2,非尿失禁孕产妇r/a比值为0.3±0.5,差异有统计学意义(P<0.01).阴道顺产组和产钳助产组孕产妇r/a比值为0.2±3.5,虽高于剖宫产组(0.2±0.2),但差异无统计学意义(P>0.05).结论 产钳助产及阴道顺产产妇的产后SUI发生率高于剖宫产.孕期发生尿失禁、产钳助产、新生儿出生体质量增加是产后SUI发生的高危因素.     

Women who gain more fat during pregnancy may not have bigger babies: implications for recommended weight gain during pregnancy

Summary. The correlation between infant birthweight and the amount of fat gained during pregnancy (estimated as the change in maternal weight between 10 weeks gestation and 2–3 weeks postpartum) was studied in 115 healthy, parous, urban Scottish housewives. There was very little correlation between these variables (  r = 0.13  , falling to  r = 0.07  after birthweight was adjusted for initial maternal weight and length of gestation), i.e., women who gained more fat during their pregnancies did not give birth to heavier babies. This suggests that for most women one of the principal effects of increasing food intake during pregnancy may be to increase maternal fat gain rather than promote fetal growth, and that efforts to increase birthweight by encouraging greater weight gain during pregnancy may be unsuccessful