Accessibility and utilisation of delivery care within a Skilled Care Initiative in rural Burkina Faso

Objectives  The Skilled Care Initiative (SCI) was a comprehensive skilled attendance at delivery strategy implemented by the Ministry of Health and Family Care International in Ouargaye district (Burkina Faso) from 2002 to 2005. We aimed to evaluate the relationships between accessibility, functioning of health centres and utilisation of delivery care in the SCI intervention district (Ouargaye) and compare this with another district (Diapaga).
Methods  Data were collected on staffing, equipment, water and energy supply for all health centres and a functionality index for health centres were constructed. A household census was carried out in 2006 to assess assets of all household members, and document pregnancies lasting more than 6 months between 2001 and 2005, with place of delivery and delivery attendant. Utilisation of delivery care was defined as birth in a health institution or birth by Caesarean section. Analyses included univariate and multivariate logistic regression.
Results  Distance to health facility, education and asset ownership were major determinants of delivery care utilisation, but no association was found between the functioning of health centres (as measured by infrastructure, energy supply and equipment) and institutional birth rates or births by Caesarean section. The proportion of births in an institution increased more substantially in the SCI district over time but no changes were seen in Caesarean section rates.
Conclusion  The SCI has increased uptake of institutional deliveries but there is little evidence that it has increased access to emergency obstetric care, at least in terms of uptake of Caesarean sections. Its success is contingent on large-scale coverage and 24-h availability of referral for life saving drugs, skilled personnel and surgery for pregnant women.     

The impact of increased lupus activity on obstetric outcomes

OBJECTIVE: Systemic lupus erythematosus is associated with multiple adverse pregnancy outcomes. We examined the impact of disease activity on spontaneous abortions, perinatal mortality, preterm delivery, and birth weight. METHODS: The study was designed to assess all pregnancies in a cohort of lupus patients who were observed prospectively from 1987 to 2002. At each visit, the physician's estimate of lupus activity was determined on a visual analog scale (high-activity lupus defined as a score of >or=2). Disease activity in each trimester was compared. We assessed the impact of high-activity lupus during pregnancy on gestational age, live birth rate, and small for gestational age babies. Potential confounders, including demographics of the women as well as maternal history of lupus, renal lupus, and antiphosphoplipid antibody syndrome, were analyzed through multivariate analysis. RESULTS: Two hundred sixty-seven pregnancies were observed. Of these, 229 (85.8%) resulted in a live birth. High-activity lupus occurred in 57 pregnancies (21%). Fewer pregnancies among women with high-activity lupus ended with live births (77% versus 88% of those with low-activity lupus; P = 0.063). Full-term delivery was achieved in 15 pregnancies (26%) among women with high-activity lupus, compared with 127 pregnancies (61%) achieving full-term in those with no or mild lupus activity (P < 0.001). High-activity lupus in the first and second trimesters led to a 3-fold increase in pregnancy loss (miscarriages and perinatal mortality). CONCLUSION: High-activity lupus during pregnancy leads to increased premature birth and a decrease in live births, with almost one-quarter of these pregnancies resulting in fetal loss. Pregnancies in lupus patients must be closely watched and treated during all trimesters to improve pregnancy outcomes.     

Pregnancy outcomes in women with thalassemia in North America and the United Kingdom

Improved survival in thalassemia has refocused attention on quality of life, including family planning. Understanding the issues associated with infertility and adverse pregnancy outcomes may impact clinical care of patients with thalassemia. We report the number and outcomes of pregnancies among subjects enrolled in Thalassemia Clinical Research Network (TCRN) registries and examine variables associated with successful childbirth. We identified 129 pregnancies in 72 women among the 264 women, age 18 years or older in our dataset. Over 70% of pregnancies resulted in live births and 73/83 (88%) of live births occurred at full term. Most pregnancies (78.2%) were conceived without reproductive technologies. Most (59.3%) pregnancies occurred while on chronic transfusion programs, however only 38.9% were on iron chelation. Four women developed heart problems. Iron burden in women who had conceived was not significantly different from age‐ and diagnosis‐matched controls that had never been pregnant. There was also no difference in pregnancy outcomes associated with diagnosis, transfusion status, diabetes or Hepatitis C infection. Pregnancies occurred in 27.3% of women with thalassemia of child‐bearing age in the TCRN registries, a notable increase from our previous 2004 report. With optimal health maintenance, successful pregnancies may be achievable. Am. J. Hematol. 88:771–773, 2013. © 2013 Wiley Periodicals, Inc.     

A uniform regimen enables decentralized care of diabetic pregnancies

Aims A nationwide recommendation to standardize the care of diabetic pregnancies in different hospitals was given in Finland in 1993. The Medical Birth Register (MBR) was used to investigate whether these recommendations have been accepted and how they have affected the outcome of newborns. Methods Data on 1442 singleton pregnancies complicated by insulin‐treated diabetes in 1991–1995 were obtained from the MBR. Results The incidence of insulin treatment during pregnancy was 4.5 per 1000 births. Sixty‐six per cent (n = 954) of all women had Type 1 diabetes. During the study period, the number of deliveries managed in tertiary centres decreased from 59% to 47% (95% confidence interval [CI] 39–58%) and care was more often carried out on an out‐patient basis. The perinatal mortality rate (≥ 28 weeks of gestation) declined from 19.3 to 8.2/1000, being 12.6/1000 in the whole diabetic population and 5.5/1000 in the general population (95% CI 3.4–8.8/1000). The risk was especially increased in insulin‐treated gestational diabetic (GDM) pregnancies (14.3/1000). The proportion of macrosomic newborns (31.7%) in diabetic women was significantly higher than among the general population (3.2%) (95% CI 27.0–33.9%). Conclusions The decentralization and change‐over to a mainly out‐patient basis of management does not appear to have increased the number of cases of adverse outcome of diabetic pregnancy when patients have been selected to the appropriate level of care. The risks in insulin‐treated GDM pregnancies were almost similar to Type 1 diabetes. To succeed, there must be a standardized care programme, continuous education and motivated personnel. Diabet. Med. 18, 871–876 (2001)     

Informants' knowledge of reproductive history and estrogen replacement

BACKGROUND: There has been much interest in assessing estrogen use in healthy older women and those with Alzheimer's disease. However, data for the women with Alzheimer's disease must be obtained from an informant. The aim of this study was to better understand what informants are likely to know about reproductive history and estrogen use. METHODS: Reproductive history data from informants of Alzheimer's patients were modeled by comparing responses from 40 cognitively healthy older women with that of a designated informant. The designated informants were similar in demographics to informants for patients with Alzheimer's disease. RESULTS: Informant data regarding reproductive history was likely to be accurate, when known. However, 30% of the subjects did not identify an informant who had personal knowledge of them. Of those informants who had personal knowledge of the subject, accuracy for those who reported that they knew the information varied depending on the aspect of reproductive history assessed (age of menarche, 29%; age of menopause, 20%; pregnancies, 63%; live births, 92%; hysterectomy, 92%; and postmenopausal estrogen use, 82%). Daughters served as the most likely and most accurate informants in this study. CONCLUSION: This study demonstrates that information obtained from informants for patients with Alzheimer's disease is likely to be accurate for some but not all aspects of reproductive history. Of concern for such studies will be the 30% of patients who do not have an informant with personal knowledge about them.     

Obstetric care in southern Tanzania: does it reach those in need?

Summary objective   To assess whether antenatal care achieves identification and timely referral of high-risk pregnancies in southern Tanzania.
methods   We compared the risk profiles of pregnant women in general with those attending obstetric care and investigated the reasons for seeking care. The risk profile of inpatients was drawn up through interviews with maternity cases and analysis of their antenatal records at the regional referral hospital ( n = 415); population-based data on the prevalence of specific risk factors were obtained from entries in antenatal care registers ( n = 1630) and from literature.
results   A significant risk selection towards obstetric referral level care was observed only for previous caesarean section (prevalence hospital 6.7% all pregnancies 1.5% P < 0.005) and for nulliparity (hospital 42.8% all pregnancies 25.0% P < 0.005). No significant differences were observed for other risk factors such as previous perinatal death height < 150 cm multiple gestation and breech presentation. Prevalence of the risk factors age > 34 years and grand multiparity was significantly lower among hospital users. Coverage of obstetric care was below 50% for all risk factors except previous caesarean section (91.5%)
conclusion   Despite pursuing the risk approach and very good coverage, antenatal care in Tanzania has only limited effect on extending obstetric care to high-risk mothers. A critical review of the present screening and counselling practices, including a more focused and client-centred application of risk assessment, is warranted.     

Maternal mortality in the main referral hospital in The Gambia, West Africa

A retrospective analysis of 78 maternal deaths was performed during 1991–1992 to estimate maternal mortality at the maternity unit of the main tertiary level hospital in The Gambia. The non-abortion maternal mortality ratio (MMR) was 736 per 100 000 live births. Among the direct causes, haemorrhage caused most deaths (24%), followed by hypertensive disorders in pregnancy (HDP) (21%). Sepsis was the main cause of death in 15%. Anaemia led among the indirect causes of death (8%) and was a co-factor in 41% of all deaths. Substandard care factors other than medical causes were determined involving health care facilities, staff, drugs and equipment, and patient-related factors. Well known risk factors of low age ( 19 years) and nulliparity were highly represented in the maternal death group, and delivery by Caesarean section occurred more than threefold compared to the overall Caesarean section rate. Taking haemorrhage as an example, it is demonstrated that the way diagnoses are grouped significantly affects the statistical elaboration of maternal deaths.     

A study of 75 pregnancies in patients with antiphospholipid syndrome

OBJECTIVE: To describe a French tertiary referral center experience in the treatment of pregnancies in patients with the antiphospholipid syndrome (APS). METHODS: Retrospective review of the data of 75 consecutive pregnancies in 47 women. RESULTS: After exclusion of induced abortions and pregnancies occurring before APS onset, the prior live birth rate was 7.9%. Forty-nine pregnancies occurred in women with history of vascular thrombosis, 17 with history of thrombocytopenia. Heparin was prescribed in 39 pregnancies, associated with aspirin in 35 cases, and aspirin alone was used in 36 as first-line therapy. Corticosteroids were prescribed in 38 pregnancies. Three pregnancies by in vitro fertilization led to one embryonic loss, one full term birth, and one premature birth. Six pregnancies treated with immunoglobulin ended in one fetal death, 2 premature and 3 full term deliveries. The outcome of the other 66 pregnancies was one embryonic loss, 8 fetal deaths, 16 prematurates, and 38 full term births. Use of corticosteroids correlated with severe prematurity (p = 0.005), preeclampsia (p = 0.014), intrauterine growth retardation (p = 0.005), and presence of disease associated to APS (p = 0.009). After exclusion of one fetal death associated with congenital anomaly, live birth rate was 72.9%. There was a trend for higher rate of fetal survival in patients without history of vascular thrombosis (84.6 vs 66.4%; p = 0.11). CONCLUSION: Obstetrical prognosis in APS was improved by antithrombotic therapy. Studies are needed to define individual risk and specific significance of the various antiphospholipid antibodies, in order to improve the respective indications for aspirin alone or with heparin in women without thrombotic events.     

National review of maternity care for women with HIV infection

OBJECTIVE: To assess adherence to the British HIV Association (BHIVA) 2001 guidelines for the management of HIV-infected pregnant women. METHODS: A survey and a case note review were carried out using structured questionnaires sent to providers of adult HIV care in the UK and Ireland. Participants were women with HIV infection who delivered a live or stillborn infant between October 2002 and September 2003. The main outcome measures were the appropriate use of antiretroviral therapy, the use and timing of elective Caesarean section, and support for the avoidance of breast-feeding. RESULTS: Of 186 centres, 100 (54%) responded with data on 501 eligible pregnancies. CONCLUSIONS: In general, practice was in accordance with the BHIVA 2001 guidelines. However, in a number of cases Caesarean sections were planned later than the recommended 38 weeks.     

Cardiac disease and pregnancy. 2. Pregnancy in the cardiac patient. 185 cases studied at the Boucicaut maternity hospital]

185 cases of pregnancy in cardiac patients followed since 1965 included 48 therapeutic abortions, 20% premature deliveries, 36 Caesarean sections, and 101 vaginal deliveries. Abortions, done by dilatation and curettage or hysterotomy, usually with tubal ligation, were performed in class III or IV cardiopathies (inoperable or relapses) and in those with decompensation in first trimester or in previous pregnancies. 10 women were operated by closed heart technique during pregnancy, usually mitral valvotomy procedures. Treatments during pregnancy included bed rest, hospitalization 2 weeks before term, low salt diet, diuretics, digitalis, calcium heparin, sedatives, and antibiotics. Prognosis depends on severity and nature of the cardiopathy, age, parity, obstetric history, and the patient's ability to follow instructions. Deliveries were originally done by Caesarean section if sterilization was planned, but recently tubal ligation is done within 2 months postpartum. 55% of the vaginal deliveries were by forceps under local anesthesia; 40% by natural chiildbirth. 4 neonates died, and 36 were premature or dysmature. Lactation was suppressed by ethinyl estradiol in almost all patients.     

Perinatal consequences of maternal hypothyroidism in early pregnancy and inadequate replacement

Maternal hypothyroidism may be associated with a variety of pregnancy complications. OBJECTIVE We have evaluated the perinatal consequences of maternal hypothyroidism in early and late gestation. DESIGN Retrospective study of pregnant women, with quasi-experimental design comparing different subjects. SUBJECTS Forty-three pregnancies In 42 women with hypothyroidism - either biochemically hypothyroid or with a history of hypothyroidism on adequate replacement - and no other preexisting medical conditions. MEASUREMENT Free thyroxine index (FTI), TSH, and haematocrit at Initial antepartum presentation and near term gestation. Pregnancy outcome variables Including: rate of Caesarean section performed for fetal distress in labour, neonatal weight percentile, and gestational age at birth. RESULTS Of 42 hypothyroid pregnancies, six were complicated by fetal distress In labour leading to Caesarean section. Five of these six were severely hypothyroid (defined as FTI ≤ 0.6 (normal range 1.1–4.4)) on initial antepartum presentation. In contrast, of the 36 pregnancies without fetal distress, only four initially presented severely hypothyroid (P<0.001). Conversely, 56% (5/9) of pregnancies which Initially presented severely hypothyroid were subsequently complicated by Caesarean section for fetal distress in labour. This compared to 3% (1/33) among those who presented either mildly hypothyroid or euthyroid on replacement (P<0.0001). Fetal distress correlated with low FTI (P<0.001) and high TSH at Initial presentation. However, It was independent of FTI near term. A relation between fetal distress and TSH near term did not reach statistical significance. Fetal distress also correlated with low maternal haematocrit on admission to labour and delivery (P<0.05), but was Independent of haematocrit and gestational age at Initial presentation, neonatal weight percentile, and gestational age at birth. CONCLUSIONS Severe maternal hypothyroidism early in gestation Is strongly associated with fetal distress in labour. This suggests that (1) Inadequate maternal replacement leads to fetal distress and (2) maternal thyroid status in early gestation may exert Irreversible effects on the fetus, the placenta, and/or on subsequent maternal adaptations to pregnancy. Early adequate replacement therapy Is especially prudent in pregnant women presenting with severe hypothyroidism.     

Trends in the incidence of coronary heart disease and stroke and the prevalence of cardiovascular risk factors among Japanese men from 1963 to 1994

PURPOSE: To determine trends in the incidence of cardiovascular disease in Japan, we examined observational data on coronary heart disease, stroke, and cardiovascular risk factors among urban Japanese working men. SUBJECTS AND METHODS: The surveyed population included all male employees aged 40 to 59 years who worked for eight industrial companies in Osaka, the second largest metropolitan city in Japan. Surveillance for cardiovascular disease and risk factors was conducted from 1963 to 1994. RESULTS: The age-adjusted incidence of coronary heart disease increased from 0.4 per 1000 person-years during 1963 to 1970, to 1.5 per 1000 person-years during 1979 to 1986, and then plateaued until 1987 to 1994 (P for trend = 0.002), whereas the incidence of stroke declined from 1.2 per 1,000 person-years during 1971 to 1978, to 0.6 per 1,000 person-years in 1987 to 1994 (P for trend = 0.02). The age-adjusted mean (+/- SD) total cholesterol level, which was 4.87 +/- 2.88 mmol/L during 1963 to 1966, increased to 5.11 +/- 0.62 mmol/L during 1982 to 1983 (P <0.001), and 5.09 +/- 0.75 mmol/L during 1990 to 1991. Both mean systolic and diastolic blood pressures increased by 1 mm Hg between the periods of 1966 to 1967 and 1982 to 1983, and declined below the 1966 to 1967 levels during 1990 to 1991. The prevalence of smoking declined from 72% during 1975 to 1976, to 58% during 1990 to 1991 (P for trend <0.001). CONCLUSION: Although these findings were limited to urban middle-aged men, the increase in serum cholesterol is likely to attenuate the reduction in future rates of coronary heart disease in Japan that would have been expected to result from the declining prevalence of smoking.     

Caesarean section to prevent transmission of hepatitis B: A meta-analysis

BACKGROUND:

Vertical transmission of hepatitis B virus (HBV) occurs in up to 10% to 20% of births.

OBJECTIVE:

To assess whether Caesarean section, compared with vaginal delivery, prevents HBV transmission.

METHODS:

A systematic review and meta-analysis was conducted. Two investigators independently searched PubMed, EMBASE and other databases for relevant studies published between 1988 and 2013. A manual search of relevant topics and major conferences for abstracts was also conducted. Randomized trials, cohort and case-control studies assessing the effect of delivery mode on vertical transmission of HBV were included. Studies assessing antiviral therapy and patients with coinfection were excluded. The primary outcome was HBV transmission rates according to delivery method.

RESULTS:

Of the 430 studies identified, 10 were included. Caesarean section decreased the odds of HBV transmission by 38% compared with vaginal delivery (OR 0.62 [95% CI 0.40 to 0.98]; P=0.04) based on a random-effects model. Significant heterogeneity among studies was found (I²=63%; P=0.003), which was largely explained by variation in hepatitis B immune globulin (HBIG) administration. Meta-regression showed a significant linear association between the percentage of infants receiving HBIG per study and the log OR (P=0.005), with the least benefit observed in studies with 100% HBIG administration. Subgroup analysis of hepatitis B e-antigen-positive women who underwent Caesarean section did not show a significant reduction in vertical transmission.

DISCUSSION:

Caesarean section may protect against HBV transmission; however, convincing benefit could not be demonstrated due to significant study heterogeneity from variable HBIG administration, highlighting the importance of HBIG in HBV prevention.

CONCLUSION:

More high-quality studies are needed before any recommendations can be made.     

Outcome of pregnancies in lupus: experience at one center

We determined the outcome of all pregnancies in SLE patients in our lupus cohort between 1991 and 1997. The women were advised that pregnancy was acceptable if the disease had been inactive for 6 months (SLEDAI < or = (4 at 2 serial examinations) and daily prednisone dose was below 10 mg. Patients were advised against pregnancy in case of active nephritis or neurolupus. In case of antiphospholipid antibodies, patients were treated with aspirin or heparin if previous fetal losses were documented. In case of anti-SSA ab, patients were monitored with ultrasound and given dexamethasone in case of atrioventricular block. Fifty-nine pregnancies were registered among 31 women: mean age at diagnosis of SLE was 25.3 +/- 3.7 years (range: 17-31); mean disease duration before pregnancy 4.4 +/- 3 years (0-14); mean ACR score 5.4 +/- 1.5 (4-9). Seven patients had ACL ab, 8 had anti-SSA ab. Pregnancies ended in: 13 early spontaneous abortions (9 not related to disease flare up, 4 related to SAPL); 7 elective abortions (patient decision in 5 cases, severe lupus flare up in 2); one in utero death; 19 full term births (> 38 weeks); and 19 preterm births. Cesarean section was performed in 11 cases (6 for fetal distress, dystocia and previous ceasarian; 5 for active lupus). Severe sepsis occurred in one premature infant who died at the age of 1 week. Intrauterine growth retardation was observed in 11 cases, mean APGAR score was 8.9 +/- 1.43. Child development was normal in all cases except one child with mild mental retardation. Severe lupus flare ups occurred in 6 cases, of which 4 were pregnancies in unadvised situations. Six mild flare ups were documented in the post partum. One fatal case of neonatal lupus with AVB was observed. In conclusion, in our experience, the live birth rate is similar to the general population and the risk of lupus flare up is low when the above mentioned criteria are applied. Systematic increase of steroid dose at pregnancy onset does not seem to be necessary. The high rate of prematurity remains a problem to be solved.     

Congenital anomalies and first life year surveillance in Type 1 diabetic births

Aims To evaluate the rate of congenital anomalies (CA) and the reasons for mortality from 22 weeks of gestation until 1 year of age in births by Type 1 diabetic mothers. Methods Population‐based cohort study using combined data from four national health registers in Finland during 1991–1995, including 954 singleton pregnancies complicated by Type 1 diabetes. Results Sixty births (629/10 000) involved registered major CA, of which 68% (n = 41) were isolated and 22% (n = 13) multiple anomalies, and in six cases, a syndrome was diagnosed (10%). After the exclusion of syndromes, the total number of anomalies was 73. Of the malformed infants, 63% were boys. The total rate of deaths among births until 1 year of age was higher in diabetic than in non‐diabetic mothers (19.9/1000 vs. 8.1/1000): especially the rates of stillborns (odds ratio 2.4; 95% confidence interval 1.2–4.7) and post‐neonatal deaths (3.8; 1.6–9.2) were higher. Of perinatal mortality (PNM) from the 22nd gestational week to the age of 7 days (13.6/1000), 23% were due to CA, 23% to prematurity, and the rest were intrauterine, mostly unexplained, deaths. Respiratory distress syndrome was the main cause of death among infants. Conclusions The rate of CAs in Type 1 diabetic pregnancies is still high, but their proportion as a cause of PNM has decreased. Though PNM rate was low, post‐neonatal mortality was significantly increased, reflecting the shift of deaths from the perinatal period to a later age.     

Relationship between reproductive patterns and infant mortality: alternative interpretations

A secondary analysis of the data of the Mexican National Fertility and Health Survey of 1987 (ENFES for its spanish acronym) was undertaken in order to study the relationship between reproductive patterns and child mortality. A total of 13,216 births and 711 infant deaths occurred 1 to 15 years previous to the survey were studied. The main conclusions are: 1) it is the adverse social, economic and environmental conditions surrounding young mothers (15 to 19 years) which are responsible for the excess mortality found in their children; 2) children of older women (35 and more years) experience increased mortality only in the late fetal period, this suggesting that a biological mechanism is mainly at stake; 3) the relative risks of death of first births, as compared to subsequent ones are generally smaller than one, indicating that first births have a lower probability of dying. The relative risk of death of first born relative to subsequent births, on the other hand, decreases with increasing age at death, suggesting that biological factors such as low birthweight and intrapartum complications are possibly important as well; 4) relative risks of death for short-spaced as compared to well spaced births were found, in general, to decrease from the late fetal to the neonatal and to the postneonatal periods. This points to a biological pathway, possibly via maternal nutrition, for the effect of spacing on child mortality.     

Prevention of venous thromboembolism in pregnancy

Pulmonary thromboembolism, rising from deep venous thrombosis (DVT), is a major cause of maternal death in the developed World. DVT is a significant source of morbidity in pregnancy and the puerperium with long-term sequelae such as post-thrombotic syndrome. The major risk factors for venous thromboembolism (VTE) are: increasing age, particularly over 35 years; operative vaginal delivery; Caesarean section, especially emergency Caesarean section in labour; high body mass index; previous VTE, especially if idiopathic or thrombophilia-associated; thrombophilia; and a family history of thrombosis suggestive of an underlying thrombophilia. Thromboprophylaxis centres largely on the use of low-molecular-weight heparin (LMWH). LMWHs, such as enoxaparin and dalteparin, have substantial clinical and practical advantages compared with unfractionated heparin, particularly in terms of improved safety with a significantly lower incidence of heparin-induced osteoporosis and thrombocytopenia. Such agents should be used in women with significant risk factors for VTE both antenatally and post-partum.     

Pregnancy in women with renal disease and moderate renal insufficiency

Data were gathered on 25 pregnancies in 23 women with moderate renal insufficiency as defined by a serum creatinine level of 1.4 mg/dl or greater prior to or at the onset of pregnancy. Twelve of the women had primary glomerular diseases, five (accounting for seven pregnancies) had interstitial diseases, and six had other renal diseases. In seven women with baseline serum creatinine levels ranging from 1.7 to 2.7 mg/dl, pregnancy was accompanied by a decline in renal function that was believed to be greater than expected from the natural history of the disease. The change ranged from a rise in serum creatinine level of 1.2 mg/dl to a functional decline that required dialysis. In 14 women (16 pregnancies), renal function either remained stable or declined to a degree consistent with the natural history of the disease. In two, the follow-up period was not long enough to judge the effect on the natural history of the disease. In 14 pregnancies, development or worsening of hypertension occurred. In nine, the diastolic blood pressure rose to 110 mm Hg or greater, and delivery was required because of hypertension. Twenty-three of 25 pregnancies ended in live births (92 percent) and 21 babies survived (84 percent). Fourteen of the 23 live births were premature. It is concluded that, in a substantial fraction of women with moderate renal insufficiency, pregnancy is accompanied by a decline in renal function; however, the fetal survival is much better than previously reported.     

Coarctation of the aorta: outcome of pregnancy.

OBJECTIVES: The study sought to determine the outcome of pregnancy in women with coarctation of the thoracic aorta. BACKGROUND: Patients with coarctation of the thoracic aorta are expected to reach childbearing age, but data on the outcome of pregnancy in this population are limited. METHODS: The Mayo Clinic database was reviewed for women of childbearing age (> or =16 years old) with a diagnosis of aortic coarctation evaluated from 1980 to 2000. Spectrum of cardiovascular disease, surgical history, and obstetrical and neonatal outcomes were determined. RESULTS: Fifty women with coarctation had pregnancies: 30 had coarctation repair before pregnancy, 10 had repair after pregnancy, 4 had repair both before and after pregnancy, and 6 had no history of repair. The 50 women had 118 pregnancies resulting in 106 births. There were 11 miscarriages (9%), 4 premature deliveries (3%), and 1 early neonatal death; 38 deliveries (36%) were by cesarean section. Of the 109 offspring, 4 (4%) had congenital heart disease. A patient with Turner syndrome died of a Stanford type A dissection at 36 weeks of pregnancy. Nineteen women (38%) were known to have hemodynamically significant coarctation during pregnancy (gradient > or =20 mm Hg). Fifteen women (30%) had hypertension during their pregnancy, 11 of whom (73%) had hemodynamically significant coarctation during that time (8 with native and 3 with residual/recurrent coarctation). CONCLUSIONS: Major cardiovascular complications were infrequent but continue to be a source of concern for patients with coarctation who become pregnant. Systemic hypertension during pregnancy was common and related to the presence of a significant coarctation gradient.     

Pregnancy before and after the diagnosis of inflammatory bowel diseases: retrospective case-control study

BACKGROUND AND AIM: Inflammatory bowel diseases (IBD) commonly affect women during the reproductive years. The aim of the present study was to evaluate the reproductive histories of patients with ulcerative colitis (UC) and Crohn's disease (CD) considering pregnancies occurring before and after the diagnosis. METHOD: Case-control study evaluating IBD patients, interviewed by questionnaire about outcome of pregnancy and course of disease. RESULTS: A total of 502 pregnancies from 199 patients in the prediagnosis group and 121 pregnancies from 90 patients in the post-diagnosis group were respectively compared with 996 and 204 pregnancies recorded in a control population. In prediagnosis pregnancies, CD was associated with increased risk of preterm delivery (odds ratio [OR] 4.62, 95% confidence interval [CI] 2.77-7.73; P < 0.001 vs controls and OR 3.52, 95% CI 1.75-7.07; P < 0.001 vs UC) and lower birthweight (P < 0.001 vs UC and controls). In post-diagnosis pregnancies, the rate of live births was lower, but not statistically significant in IBD (OR 0.22, 95% CI 0.04-1.25; P = 0.08) and the birthweight was significantly lower in CD than in UC (P < 0.03) and in controls (P < 0.02). In post-diagnosis pregnancies, a higher incidence of congenital abnormalities was found in IBD patients (5.5% vs 0.0%). The spontaneous abortion rate and therapeutic abortions were significantly higher in post than in prediagnosis pregnancies. Neither disease activity at conception nor treatment appeared to influence the outcome of pregnancy. CONCLUSIONS: CD in the preclinical phase has some influence on pregnancy. In patients with IBD our data suggest that conception should not be discouraged. However, because of a modest increase in mild congenital abnormalities and abortions rates, pregnancy in IBD patients should be closely monitored.