Antepartum Complications of Pregnancy

Pregnancy presents unique considerations and challenges to the critical care provider, including the physiologic adaptations to the pregnant state, recruitment and collaboration with a multidisciplinary care team, determination of fetal status, preparing for and managing cardiac arrest in pregnancy, and evaluation and management of diseases unique to pregnancy (including preeclampsia and acute fatty liver of pregnancy). This review contains 48 references, and 4 tables. Key words: acute fatty liver of pregnancy, maternal cardiac arrest, perimortem cesarean section, preeclampsia, pregnancy

Study on maternal and perinatal outcome of pregnancy with history of previous caesarean section

Background: This is a Prospective observational study conducted in Department of Obstetrics and Gynaecology, BSMMU, Dhaka.Objective: The purpose of this study was to evaluate maternal and perinatal outcome of pregnancy with history of previous caesarean section.Method: Data were collected as per questionnaire by researchers herself by interviewing the patients and by observing the operations, investigation records and post-operative follow-up. A total number of 150 patients admitted with pregnancy with history of one or more previous caesarean section.Outcome measure: To find out antepartum complications, per-operative and post-operative complications specially related to previous caesarean section and to find out perinatal mortality and morbidity.Results: Among 150 patients who were delivered after one or more previous caesarean section, 88 (52%) patients had antepartum complications, the majority (88%) pregnancies were term pregnancy. The per-operative problem was difficulty to reach lower uterine segment due to adhesion with bladder was 16%. Overall post-operative complications were 20% cases. The common complications were wound infection (86%). Perinatal complications were 20 (30%) cases.Conclusion: The wide spread improvement in anaesthesia, surgical technique, antibiotics and blood transfusions have decreased the morbidity and mortality from caesarean section, but it is not without hazard.Bangladesh Journal of Medical Science Vol.15(3) 2016 p.392-398

The Effect of Comprehensive Care and Degree of Iron Overload on Maternal and Fetal Outcomes in Pregnancies of Transfusion-Dependent Beta-Thalassemia Patients

Abstract 5297 Introduction: Iron overload resulting in hypogonadotrophic hypogonadism is the major cause of infertility in patients with beta-Thalassemia Major (bTM). However, in patients who are able to achieve pregnancy, the effects of iron overload and comprehensive care by hematologists specialized in Hemoglobinopathies on maternal-fetal outcomes have not been well-documented. We hypothesize that in patients with transfusion-dependent bTM, lack of comprehensive care prior to conception or elevated ferritin is associated with poor maternal-fetal outcomes and increased rates of antepartum complications. Methods: A retrospective review was conducted on transfusion-dependent bTM patients who delivered at the Mount Sinai Hospital (MSH), a quaternary referral, high risk obstetrics care institution in Central Ontario, Canada, between 2000 and 2010 based on the Antenatal Database, Delivery Database, electronic and paper-based medical records. Patients were jointly managed by a maternal-fetal medicine specialist and hematologist specialized in hemoglobinopathies. All forms of chelation were discontinued during pregnancy. We analyzed the maternal-fetal outcomes and antepartum complications based on the presence or absence of comprehensive care prior to pregnancy by the Red Blood Cell Disorders (RBCD) Clinic at the University Health Network, a hemoglobinopathy comprehensive care centre from the same catchment area as MSH. Components of comprehensive care include regular monitoring of iron burden, screening and treatment of target organ damage from iron overload, genetic counseling from physicians, and psychosocial counseling from a social worker. We also analyzed the relationship between the pre-pregnancy ferritin levels and birth weight, gestational age, and any antepartum complications. Results: We identified 40 singleton deliveries and 3 twin deliveries by 42 patients (40 bTM, 1 Thalassemia Intermedia, 1 Hemoglobin E/beta-Thalassemia). There were no maternal or fetal deaths. The 3 twin pregnancies were excluded from analysis due to being a potential confounder in maternal and fetal outcomes. Mean maternal age at delivery was 33.11 years (95% CI 31.77, 34.45 years). Mean gestational age at delivery was 38.29 weeks (95% CI 37.41, 39.17 weeks) with six (15%) pre-term births (<37 weeks). Fourteen deliveries (35%) were by Caesarian section and 26 were vaginal deliveries. Six (15%) were low birth weight (<2500 g) and 2 (5%) were small for gestational age. Ten of the 39 patients analyzed (11 deliveries) received comprehensive care at RBCD clinic prior to their pregnancies. There was no significant difference in maternal-fetal outcomes or antepartum complications between patients who received comprehensive care prior to conception and those who did not. However, patients who received comprehensive care were significantly younger and had lower parity (P = 0.0072 and 0.0276 respectively). In the 19 deliveries where pre-pregnancy ferritin was available, there was no association between pre-pregnancy ferritin and fetal birth weight, gestational age, or any antepartum complications. Discussion: There was no association between pre-pregnancy ferritin level and maternal-fetal outcomes. Presence of comprehensive care prior to conception did not appear to significantly change the maternal-fetal outcomes in transfusion-dependent beta-Thalassemia patients. We speculate that the lack of difference may be due to a higher proportion of primigravida in the comprehensive care group acting as a potential confounder, given that primigravida in general have higher rates of adverse pregnancy outcome. In addition, patients with higher parity may have less severe complications from iron overload, and consequently are less likely to be referred to a comprehensive care center. Limitations include small sample size and single center study. Further prospective observational studies with larger sample size are required to evaluate whether a) introduction of uniform comprehensive care to all women with bTM in child-bearing age will improve pregnancy outcomes; b) ferritin or liver iron concentration is useful in predicting antepartum complications in bTM patients. Disclosures: Kuo: Novartis Canada: Research Funding.

The Effect of Comprehensive Care on Maternal and Fetal Outcomes in Sickle Cell Disease Pregnancies

Abstract 4842 Introduction: Patients with Sickle Cell Disease (SCD) have increased rates of maternal and fetal complications compared to the general population, including premature rupture of membranes, post-partum infection, low birth weight, small for gestational age (SGA), intrauterine growth retardation (IUGR) and preterm delivery. They also experience higher rates of antepartum complications: painful vasoocclusive crises (VOC), infections, PIH/preeclampsia, abruption, antepartum bleeding, cardiomyopathy, pulmonary hypertension, cerebral vein thrombosis, pneumonia, pyelonephritis, deep vein thrombosis (DVT), transfusion and systemic inflammatory response syndrome. Comprehensive care reduces morbidity and mortality in infancy and early childhood and is the cornerstone of care in SCD. However, the effect of comprehensive care on maternal and fetal outcome in patients with SCD has not been examined. We hypothesize that pre-conception comprehensive care improve maternal and fetal outcomes and reduced rates of antepartum complications in patients with SCD. Methods: We conducted a retrospective review of patients with SCD (SS, SC, S/beta-thalassemia) who delivered at the Mount Sinai Hospital (MSH), a high risk obstetrics care institution in Central Ontario, Canada, between 2000 and 2010 based on the Antenatal Database, Delivery Database, electronic and paper-based medical records. Patients were jointly managed by a maternal-fetal medicine (MFM) specialist and hematologist specialized in hemoglobinopathies. We analyzed the maternal and fetal characteristics and outcomes (age at delivery, genotype, gravida, gestational age, birth weight, number of Caesarian sections and vaginal deliveries), antepartum complications (pregnancy induced hypertension (including pre-eclampsia and eclampsia), gestational diabetes mellitus, preterm premature rupture of membranes, oligohydramnios, abruption/previa, venous thromboembolism, urinary tract infection), and SCD-specific complications (painful vaso-occlusive crises, acute chest syndrome, pneumonia, and transfusion) based on the presence or absence of comprehensive care prior to pregnancy by the Red Blood Cell Disorders (RBCD) Clinic at the University Health Network, a SCD comprehensive care centre from the same catchment area as MSH. t-test was used to compare means of two groups, Fisher's exact test and chi-squared tests were used to compare categorical frequency data, where appropriate. Alpha value of 0.05 was chosen as the level of significance. Results and Discussion: We identified 79 deliveries by 64 patients with SCD who received obstetric care at MSH. Mean gestational age at delivery was 37.69 weeks (95% CI 37.00 to 38.37 weeks) and 21 (27%) were preterm (< 37 weeks). Thirty-one deliveries (39%) were by Caesarian section and 48 were delivered vaginally. Seventeen (22%) were low birth weight (< 2500 g) and 11 (14%) were small for gestational age. Maternal and fetal outcomes and rates of antepartum complications were similar to the existing literature (Powars, 1986; Smith, 1996; Serjeant, 2004; Barfield, 2010). Twenty-eight deliveries by 22 of the 64 patients received comprehensive care at the RBCD clinic prior to their pregnancies for a mean duration of 5 years. There was no significant difference in maternal or fetal outcomes or antepartum complications. The results suggest that the role of comprehensive care prior to conception may not be as crucial in pregnancy outcomes of patients with SCD as previously thought. The lack of difference may also be due to the fact that the patients' care was closely monitored during the pregnancy by both specialists in hemoglobinopathies and high risk obstetrics. Limitations of the study include its single-centered and retrospective nature, exclusion of stillbirths and miscarriages, and small sample size. Also, patients who were enrolled in the comprehensive care program may carry more comorbidities and SCD-specific complications, compared to patients referred from the community, but this was not examined in the present study. Further prospective observational studies of SCD patients in the child-bearing age, with attention to the frequency and type of pre-pregnancy SCD-specific complications, as well as standardized application of comprehensive care, will be helpful in determining whether comprehensive care is useful in reducing antepartum complications in patients with SCD. Disclosures: Kuo: Novartis Canada: Research Funding.

The Relationship Between Pre-Pregnancy Sickle Cell Disease-Specific Complications and Maternal and Fetal Outcomes in Sickle Cell Disease Pregnancies

Abstract 4848 Introduction: Patients with sickle cell disease (SCD) have worse maternal and fetal outcomes compared to the general population, and experience antepartum complications unique to SCD patients, including painful vasoocclusive crises (VOC), acute chest syndrome (ACS), stroke and symptomatic anemia. The relationship between pre-pregnancy SCD-specific complications and maternal/fetal outcomes and antepartum complications has not been explored. We hypothesize that increased rates of SCD-specific complications are associated with increased rates of antepartum SCD-specific complications and worsened maternal and fetal outcomes. We further hypothesize that elevation in fetal hemoglobin is associated with improved maternal/fetal outcomes. Materials and Methods: We conducted a retrospective review of patients with SCD (SS, SC, S/beta-thalassemia) whose pregnancies were managed at the Mount Sinai Hospital (MSH), a high risk obstetrics care institution in Ontario, Canada, between January 1st, 1999 and June 30th, 2009 based on the institution's electronic and paper-based medical records. Patients were jointly managed by a hematologist specialized in hemoglobinopathies and an obstetrician specialized in high risk obstetric care. We compared the pre-pregnancy and antepartum rates of SCD-specific complications (painful VOC, ACS, stroke, and on-demand transfusion requirements). Pre-pregnancy fetal hemoglobin level was analyzed according to the presence or absence of maternal/fetal complications (expressed as an aggregate of preterm delivery, placental insufficiency, low birth weight (<2500 g), the need of emergent Caesarian section, fetal anomalies and fetal death). The t-test was used to compare means of the two groups. Fisher's exact test was used to compare categorical frequency data. An alpha value of 0.05 was chosen as the level of significance. Results and Discussion: We identified 22 pregnancies in 22 patients with SCD, 4 patients had not delivered at the time of censor. Fourteen patients were HbSS, 7 were HbSC, 1 was HbS/beta-thalassemia. Mean maternal age was 31.1 years. Mean gestational age at delivery was 37 weeks (95% CI 36 to 38 weeks) and 5 (23%) were preterm (< 37 weeks). Eleven of the 18 deliveries (61%) were by Caesarian section and 7 were performed on an emergent basis (4 due to fetal distress and 3 due to failure to progress). Three (17%) were low birth weight (< 2500 g) and 2 (11%) were intrauterine growth restricted. Maternal and fetal outcomes and rates of antepartum complications were similar to the existing literature. There was no association between prior history of ACS and having an episode of ACS during pregnancy. A history of painful VOC was associated with having at least one episode of painful VOC during pregnancy (P = 0.0433). Pre-pregnancy history of on-demand red cell transfusion was also associated with the need of at least one unit of transfusion during pregnancy (P = 0.0048). However, the frequency and time of first painful VOC during pregnancy were not associated with worsened maternal/fetal outcome. There was no association between fetal hemoglobin level and antepartum rates of painful VOC (P = 0.4867), ACS (P = 0.3702), and maternal/fetal complications (P = 0.2489). The results suggest that patients with a history of painful VOC may be predisposed to having painful VOC during pregnancy. Similarly, patients with a history of on-demand transfusion may need transfusion during pregnancy. The present study is limited by small sample size and its single-centered and retrospective nature. Further observation studies with larger sample size are required to prospectively validate these results. Disclosures: Kuo: Novartis Canada: Research Funding.