Risk Of Obstetric Complications Research Articles

Insulin Aspart in Diabetic Pregnancy: State of the Art

Pregnancy in women with diabetes is associated with an increased risk of obstetric complications and perinatal mortality. Maintenance of near-normal glycemia during pregnancy can bring the prevalence of fetal, neonatal and maternal complications closer to that of the nondiabetic population. Changes in insulin requirements during pregnancy necessitate short-acting insulins for postprandial control of hyperglycemia. The fast-acting insulin analogue insulin aspart has been tested in a large, randomized trial of pregnant women with Type 1 diabetes and offers benefits in control of postprandial hyperglycemia with a tendency towards fewer episodes of severe hypoglycemia compared with human insulin. Treatment with insulin aspart was associated with a tendency toward fewer fetal losses and preterm deliveries than treatment with human insulin. Insulin aspart could not be detected in the fetal circulation and no increase in insulin antibodies was found. Thus, the use of insulin aspart in pregnancy is regarded safe.

The effects of genetic liability for schizophrenia and maternal smoking during pregnancy on obstetric complications

The purpose of this study was to determine whether a genetic vulnerability for schizophrenia and/or health-risk behaviors among schizophrenic pregnant women were associated with an increased incidence of obstetric complications (OCs). Method A high-risk birth cohort was formed by searching the Finnish Perinatal Register for all births from 1991–2000 with arterial cord pH values below 7.20, an indication of fetal asphyxia. This database was merged with national hospital discharge registries to determine psychiatric morbidity of the mothers and the mothers' first-degree relatives. Mothers were divided into 3 groups: women diagnosed with schizophrenia/schizoaffective disorder ( n = 53), mothers with a first-degree relative with schizophrenia/schizoaffective disorder ( n = 590) and healthy controls ( n = 36,895). Result Schizophrenic women had significantly more OCs than mothers with a first-degree schizophrenic relative and controls. These women had significantly increased rates of eclampsia, premature delivery, prenatal hospitalizations, and marginally significant increases in high blood pressure. Offspring of schizophrenic mothers had significantly decreased APGAR scores and birth weight and increased medical complications after birth. In contrast, women with a schizophrenic first-degree relative had no significant increases in OCs compared to controls. Schizophrenic mothers also smoked more than the other groups and smoking was found to mediate the relationship between maternal schizophrenic status and decreased birth weight among offspring. Conclusions Maternal schizophrenia during pregnancy leads to an increased risk of OCs, possibly due to engagement in health-risk behaviors during pregnancy, such as smoking, whereas genetic susceptibility to schizophrenia, by itself, does not appear to be related to incidence of OCs.

Obstetric outcome following laparoscopic adjustable gastric banding

Objective To evaluate obstetric outcomes following laparoscopic adjustable gastric banding (LAGB) in obese women. Methods Obstetric outcomes were compared in a retrospective case–control study with 427 obese women, 13 who underwent LABG and 414 who did not. Results The mean weight gain during pregnancy was significantly lower in the LABG group than among controls (5.5 kg vs. 7.1 kg; P < 0.05). The incidence of pre-eclampsia, gestational diabetes mellitus, low birth weight, and fetal macrosomia was less in the LABG group ( P < 0.05), and the incidence of cesarean deliveries during labor was half in the LAGB group (15.3% vs. 34.4%; P < 0.01). Neonatal outcomes were not significantly different in the 2 groups. Conclusions Among obese women, the incidence of adverse obstetric outcomes was less in those who underwent LABG than in those who did not. These results suggest that obese women who wish to become pregnant would decrease their risk of obstetric complications if they first underwent LAGB.

Management of Epilepsy during Pregnancy

Managing epilepsy during pregnancy is to balance the maternal and fetal risks associated with uncontrolled seizures against the potential teratogenic effects of antiepileptic drugs (AEDs). A rational approach requires knowledge of such risks as well as an understanding of the effects of pregnancy on seizure control and of gestational effects on AED disposition. Uncontrolled tonic-clonic seizures are potentially hazardous to the mother and, although strict evidence is lacking, are generally also assumed to be more harmful to the fetus than are AEDs. However, infants who have been exposed to AEDs in utero run an increased risk of congenital malformations: approximately twice the rate reported in the general population. Earlier literature has largely failed to demonstrate differences in birth defect rates with different treatment regimens, which can be ascribed mainly to insufficient sample sizes. More recent data have indicated higher malformation rates with exposure to valproic acid compared with some other major AEDs. The teratogenic effects of valproic acid appear to be dose dependent, with higher risks at dosage levels >1000 mg/day. Polytherapy involving treatment with more than one AED also seems to be associated with an increased risk of birth defects compared with monotherapy. Recently, a few small-scale studies have investigated the possibility that exposure to AEDs in utero may adversely affect the postnatal cognitive development of the offspring. Some of these studies have suggested that valproic acid poses a higher risk compared with other AEDs in this respect. These signals are important, but must be interpreted with caution because of the methodological shortcomings of the studies and because adequately powered prospective studies are necessary to draw firm conclusions. More reassuring findings have emerged regarding the obstetric outcome of pregnancy and the risk of worsening of epilepsy during pregnancy. In particular, it seems that the risk of obstetric complications is not significantly increased. Furthermore, most of the women with epilepsy have no change in their seizure frequency during pregnancy. The disposition of many AEDs may change during pregnancy, reflected in declining plasma drug concentrations. This seems to be most pronounced for lamotrigine and possibly also for oxcarbazepine, and can result in break-through seizures. The common treatment strategy has been to use the appropriate AED for the woman's seizure disorder as monotherapy in the lowest effective dosage throughout pregnancy, the objective being to use AEDs in such a way that generalised tonic-clonic seizures are avoided but with minimised risks to the fetus, the newborn and the breast-fed infant. Valproic acid should be avoided if possible. Any major change in the treatment of a woman with epilepsy should ideally be completed before conception. Regular monitoring of drug concentrations is recommended during pregnancy, in particular for lamotrigine and oxcarbazepine.

Protein Z Levels Could Help To Predict Obstetrical Complications and Arterial Thrombosis in Patients with Antiphospholipid Antibodies.

Introduction: Protein Z (PZ) is a vitamin K dependant plasma protein synthesized by the liver. The precise physiological function of PZ is still unclear: - anticoagulant, the PZ-dependant protease inhibitor complex inhibits factor Xa and acts as a naturally occurring anticoagulant; - procoagulant, PZ promote the assembly of thrombin with PL vesicles- and promote coagulation. In clinical situations, low PZ plasma levels have been associated with bleeding and thrombotic tendency while elevated PZ plasma levels have been linked with ischemic stroke. Antiphospholipid syndrome (APS) is a complex autoimmune thrombotic disorder. Despite specific clinical and laboratory criteria, diagnostic and prognostic tools in patients with APS are limited in their ability to predict adverse outcome in patients with antiphospholipid antibodies (aPLA). Therefore, we hypothesized that PZ could play a role in the thrombotic tendency.Study: to evaluate our hypothesis, we measured PZ plasma concentrations in a case control study including 61 patients with confirmed aPLA with or without APS versus 53 controls. Among the group of patients with APS, 15 had obstetrical complications (OC), 16 had arterial thrombosis (AT) and 11 venous thrombosis (VT). Nineteen patients had aPLA without APS defining the APS(−) group. Plasma PZ antigen concentrations were measured on citrated plasma using the commercial ELISA kit, Asserachrom protein Z, (Diagnostica Stago).Results: PZ plasma levels were normally distributed. Normal PZ concentrations defined as mean ±2 SD were contained between 0.4 and 2.6 μg/mL. No difference was found in mean+ SD between male and female. Two per cents of controls and 18% of patients with venous thrombosis had PZ under 0.4 μg/mL. Forty per cents of patients with OC, 25% with AT and 18% with VT had PZ above 2.6 μg/mL. Plasma protein Z levels measured at least 6 month after any clinical event were significantly higher in APS patients than in controls and APS(−) patients [mean ± SD μg/mL, 2.0 ± 0.9 vs 1.5 ± 0.5 and 1.3 ± 0.5 respectively). According to the clinical complications, PZ concentrations were significantly greater in the group with OC (2.4+0.6 μg/mL) and AT (2.05+0.8 μg/mL) than in controls (1.5+0.5 μg/mL), VT(1.3+0.9 μg/mL) and APS(−) (1.3+0.5 μg/mL) patients [OC vs Controls: p<0.0001; AT vs Controls: p= 0.0047; OC vs AT: p= NS; OC vs APS(−):p< 0.0001; OC vs VT: p= 0.0016, APS(−) vs controls: NS; APS(−) vs VT: NS; VT vs Controls: NS; APS(−) vs AT: p=0.0034; AT vs VT: p= 0.05]. We found an increased relative risk of OC and AT with increasing PZ levels with odds ratios of 7.1 [95% CI: 2.1–23.7] for OC and 2.4 [95% CI: 1.1–5.4] for AT.Conclusion: our study retrospective on a small size sample, indicates that high protein Z plasma could be a high risk for obstetrical complications and a lower risk for arterial thrombosis in aPLA patients. Measure of PZ could help to evaluate obstetrical and thrombotic risk of patients with aPLA. Further prospective studies are needed to confirm our results.

Screening for smoking and substance misuse in pregnant women with mental illness

Aims and MethodSmoking and substance misuse adversely affect the outcome of pregnancy and psychiatric patients are known to smoke more than other patients. Data collected at the time of routine antenatal booking were analysed to investigate whether pregnant women with mental health problems smoke more than other pregnant women.ResultsData were collected from 156 women. Those with a psychiatric diagnosis (n=76) were significantly more likely to smoke (P&lt;0.001). Associations were also found with illicit drug use and previous termination of pregnancy. The most common psychiatric diagnosis was depression (62%). A diagnosis of schizophrenia was not recorded for any of the women.Clinical ImplicationsThe strong association between smoking and psychiatric diagnosis results in an increased risk of obstetric complications in psychiatric patients. Anti-smoking interventions might be delivered by adequately trained midwives and opportunistically during contact with mental health professionals.

Management of missed abortion in a patient with congenital uterine anomalies

Uterine anomalies are rare entities, vary from 0.1 to 4%, and are related to an increase risk of obstetrical complications. We report a case of a uterine anomaly, diagnosed during the management of a patient who presented with a missed abortion.

The silent truth of teenage pregnancies--Birth to Twenty cohort's next generation.

The silent truth of teenage pregnancies--Birth to Twenty cohort's next generation.

Impact of reduced prenatal visit frequency on obstetric outcome in low-risk mothers.

To determine an association between reduced prenatal visit frequencies and pregnancy outcome in women, found to be at low-risk of obstetric complications at initial prenatal visit. Prospective cohort study. Mother and Child Health Center, Pakistan Institute of Medical Sciences, Islamabad. from January to December 2002. The hospital case records of 1290 women, who were found to be at low risk of obstetric complications at their first prenatal visit. Prenatal visits were categorized into '<3', '3-6' and 'z 7 visits groups'. 'z7 visits were taken as controls. The main outcome measures were peripartum maternal complications, obstetric interventions and perinatal outcome. The median number of prenatal visits was four, (range 1-14; lower quartile 2, upper quartile 6). Women with less than 3 prenatal visits had significantly higher risk of antepartum complications, low birth weight neonates (<2500 grams), pre-term deliveries, neonatal morbidity, and peri-natal mortality. (OR: 2.58, 2.66, 6.3, 1.57 and 2.2 respectively). However, they were at equal risk of obstetric interventions and postpartum maternal morbidity. No significant difference was found between 3-6 visits and z7 visits group, except significantly higher risk of preterm deliveries in the former group (OR: 2.84). Less than 3 prenatal visits were associated with significantly higher incidence of prenatal feto-maternal complications and low birth weight babies compared to 7 or more visits but were at equal risk of obstetric interventions and postpartum maternal morbidity.The obstetric outcome of 3-6 visits group was similar to 7 or more visits group except considerably higher incidence of preterm deliveries in the former group.

Outcome in pregnancies complicated by myotonic dystrophy: a study of 31 patients and review of the literature

Objectives: Myotonic dystrophy can be associated with increased obstetric risks, but the maternal contribution for gestational outcome is difficult to establish considering the varying degrees of severity and the influence of fetal factors. Study design: We analyzed the pregnancy course and outcome of 31 women with classic myotonic dystrophy, who delivered a total of 66 children. In addition, 93 gestations from the literature were reviewed. Results: As most patients were not aware of their diagnosis at reproductive age, often the first indication of the maternal disease was a severely affected child (39%). Miscarriages and pre-eclampsia did not increase. Ectopic pregnancies occurred in 4%, placenta previa in 9% of gestations, while postpartum hemorrhage due to uterine atonia was only reported twice. Severe urinary tract infections were reported for 19% of the patients, but were only rarely encountered in the literature. Preterm labor, before 34 weeks, occurred in 19% of gestations and was often, but not exclusively attributed to congenitally affected fetuses in contrast to polyhydramnios (17%). Labor abnormalities of all three stages were frequent, increasing the number of operative deliveries (cesarean section rate 36%). Perinatal mortality was 15% and mainly related to congenitally affected children. Conclusions: The risk for obstetric complications and urinary tract infections increases for pregnant patients with myotonic dystrophy. They need constant obstetric monitoring. It is hoped that a better awareness of the clinical picture might help to improve gestational outcome in myotonic dystrophy.

Pregnancy outcome in lupus nephropathy.

The maternal and fetal outcomes of 55 pregnancies in 24 patients with pre-existing lupus nephritis (LN) were retrospectively analysed. The risk factors for poor fetal outcome were evaluated. The patients were divided into two groups. Patients in Group A had quiescent LN and those in Group B showed clinical evidence of active LN at conception. In Group A, of the 36 pregnancies in 16 patients, 11 resulted in term deliveries without complications, 9 in spontaneous abortions, 6 in preterm deliveries, 3 in intrauterine growth retardation (IUGR) and in 2 stillbirths. In Group B, of the 19 pregnancies in 8 patients, there were 6 spontaneous abortions, 3 uncomplicated term deliveries and 10 pregnancies were complicated by hypertension. Gross IUGR occurred in 3 pregnancies. There were 3 stillbirths and 1 neonatal death in the study. Total fetal loss was 38.2% and the perinatal mortality (PNM) rate, 150/1,000 deliveries. Two mothers, both from Group B died in the series, 1 from multisystem failure of systemic lupus erythematosus, 3 days after delivery and the second died from irreversible renal failure 2 months after caesarean section. Pregnant women with long-standing LN are at high risk of spontaneous abortions and increased PNM. However, the outlook of pregnancy in patients with stable LN at conception is relatively favourable. The risk of obstetric complications and maternal mortality is high in patients with active lupus nephropathy associated with pre-existing hypertension. Pregnant women with LN require intense fetal and maternal surveillance for the best outcomes of pregnancy.

Treatment of syphilis in pregnancy and prevention of congenital syphilis.

Studies about the management of syphilis during pregnancy were reviewed. They lacked uniformity in diagnostic criteria and study design. Currently recommended doses of benzathine penicillin G are effective in preventing congenital syphilis in most settings, although studies are needed regarding increased dosing regimens. Azithromycin and ceftriaxone offer potential alternatives for penicillin-allergic women, but insufficient data on efficacy limit their use in pregnancy. Ultrasonography provides a noninvasive means to examine pregnant women for signs of fetal syphilis, and abnormal findings indicate a risk for obstetric complications and fetal treatment failure. Ultrasonography should precede antepartum treatment during the latter half of pregnancy to gauge severity of fetal infection. However, optimal management of the affected fetus has not been established; collaborative management with a specialist is recommended. Antepartum screening remains a critical component of congenital syphilis prevention, even in the era of syphilis elimination.

The prevention of schizophrenia: what interventions are safe and effective?

Obstetric complications appear to increase the risk of developing schizophrenia, and post-World War II improvements in obstetric care may have contributed to a decline in the incidence of the illness in the developed world. Educating providers and consumers of psychiatric and obstetric services about the risk of obstetric complications in increasing the risk of schizophrenia could bring about a further small decrease in the incidence of the illness, safely and at low cost. On the other hand, attempts to prevent the occurrence of schizophrenia by treating people who manifest high-risk indicators prior to the development of the illness have a low probability of success and a high probability of unintended negative consequences. Early intervention with people who have developed the full schizophrenia syndrome is likely to have few negative effects and may yield benefits, although it is not yet clear that it will.

Risk for obstetric complications and schizophrenia

The goal of this study was to determine whether cases with schizophrenia or related disorders show a history of obstetric complications significantly more often than control subjects and, if so, whether the enhanced risk of a negative pregnancy outcome also extends to the non-schizophrenic offspring of cases. Data based on the obstetric birth case-notes of patients with diagnosed schizophrenia or related disorders were compared to those of normal ‘healthy’ control subjects; each case/control pair was individually matched by gender, time and parity of birth, maternal age and marital status. Forty-four case/control pairs born in Padova (Italy) between 1964 and 1978 were assessed for prenatal and perinatal complications, including abnormal gestational age or birthweight. No significant differences were observed between cases and control subjects in the general characteristics of birth; gestational age and birthweight in particular were strictly comparable between cases and control subjects. The schizophrenia spectrum patients (75%) were more likely than control subjects (59%) to have experienced at least one definite obstetric complication: odds ratio=2.07 (95% CI: 0.83–5.15). Cases also suffered more complications per birth than control subjects (average 2:1). In particular, obstetric complications involving a clear damaging potential were seen significantly more often among cases than control subjects: 34% vs. 9%, Fisher’s exact test, P=0.008 (odds ratio=5.17, 95% CI: 1.55–17.21). Moreover, severe obstetric complications were noted more often among males ( n=13, 41%) than females ( n=2, 15%). When any previous pregnancies of the mothers of patients were compared with those of the mothers of control subjects, mothers of cases were seen to have suffered unfavorable pregnancy outcomes significantly more often. In particular mothers of cases were seen to have had more miscarriages (OR=4.66), and pre-term births (OR=2.58) than control subects’ mothers. Severe, brain-damaging obstetric complications would seem to be a possible antecedent to a diagnosis of schizophrenia or a related disorder in adulthood. Indeed, some early onset cases may be accounted for by prenatal brain lesions. This enhanced risk of negative pregnancy outcome may be under genetic control, contributing to the persistence of schizophrenia in the general population. The ‘healthy’ status of control subjects was ascertained indirectly, not by individual assessment of the subjects. The sample size limits the statistical power of calculations.

Venous Thrombectomy in Pregnancy: A Follow-up Study

Objective: To evaluate women who have been treated by venous thrombectomy in pregnancy because of iliofemoral venous thrombosis, reporting the outcome of their pregnancy and frequency of objectively measured venous insufficiency. Design: A retrospective study. The patients were assessed by questionnaire, clinical examination, tests of venous function and ultrasonography. Setting: Department of Vascular Surgery, Gentofte Hospital, University of Copenhagen. Patients: Nineteen women treated previously by venous thrombectomy during pregnancy, with a subsequent pregnancy. Results: None of the women had complications during subsequent pregnancies or deliveries, 47% had an occluded iliac segment and 53% had dilated or varicose veins. None had ulcers or skin changes. None of the women showed signs of of re-thrombosis. Conclusion: Women who have been treated for deep venous thrombosis in pregnancy by thrombectomy and arteriovenous fistula followed by anticoagulant therapy may undergo further pregnancies with a very low risk of obstetric complications and a low risk of developing re-thrombosis or chronic venous insufficiency.

Outcomes of high-order multiple implantations in women undergoing ovum donation.

Increasing numbers of young women with ovarian failure and women of advanced reproductive age (> 40 yrs) utilize oocyte donation to treat their infertility. In both groups, women who become pregnant frequently experience multiple gestation, occurring in up to 30% of pregnancies. Advanced maternal age and high-order multiple gestations are associated with an increased risk for obstetric complications. We reviewed the pregnancies of patients with high-order multiple gestations (> or = 3 gestational sacs) with respect to their antepartum course and neonatal outcomes. Mothers were divided into two groups according to age at conception; Group I (> or = 40 yr, n = 20) and Group II (< 40 yr, n = 10). These 30 high-order multiple gestations were found among 127 successful oocyte donation cycles (23.6% of all pregnant patients). Data regarding pregnancy outcomes were gained by chart review and telephone interview. Results demonstrated spontaneous reductions in the number of implantation sites were similar between groups (Group I: 21.4% vs. Group II: 17.6%). Multifetal pregnancy reduction (MFPR) was more often chosen by older women (Group I: 45% vs. Group II: 10%; P < 0.05). Antenatal complications were commonly experienced by both groups (> 80%) as were operative deliveries (> 85%). However, neonatal outcomes were generally good, with only one death occurring in the 79 delivered infants (1.3%). We conclude transferring supernumerary embryos to women undergoing ovum donation places patients at great risk for high-order multiple gestations. These pregnancies are associated with increased antenatal and neonatal complications. Although advanced maternal age is normally an added risk factor, well-screened older patients carrying high-order multiple gestations experienced similar outcomes as younger mothers.

Pregnancy in lupus nephropathy

The purpose of this study was to obtain information about the fetal and maternal outcome of pregnancy in patients with pre-existing lupus nephritis and to evaluate risk factors for poor fetal outcome. Twenty-six pregnancies in 16 patients were retrospectively analyzed. Induced abortions were performed in two patients and one patient had a spontaneous abortion. Of the 23 completed pregnancies, all clinically established on inactive lupus nephritis with normal renal function, seven (30%) were complicated by pre-eclampsia. Two of the three patients with severe pre-eclampsia had increased levels of antiphospholipid antibodies (aPL). Of the 23 newborns, seven (30%) were premature (< 37 weeks) and seven (30%) had neonatal complications. Six of the seven pregnancies associated with neonatal complications were hypertensive. There was one early neonatal death. Four newborns (16%) were severely growth retarded (< -2 SD). The presence of hypertension before pregnancy tended to correlate with low relative birth weight in the newborns (p = 0.079). Flares of systemic lupus erythematosus (SLE) during pregnancy and six months post partum occurred in two (9%) of the 23 completed pregnancies. Renal function was not affected irreversibly in any patient. Thus, the outlook for pregnancy in patients with stable lupus nephritis at conception is good. However, the risk of obstetric complications is greater and fetal morbidity, especially in hypertensive pregnancies, is common.

The Role of Obstetric Complications in Schizophrenia

The importance of obstetric complications in sporadic and familial psychoses was analyzed in 43 schizophrenic and 28 chronic schizoaffective patients. Patients and first-degree relatives were diagnosed using Research Diagnostic Criteria and the best-estimate procedure. Mothers of patients were interviewed for histories of pregnancy and obstetric complications in their offspring. Patients had more often suffered perinatal complications (42%) than their siblings (29%). The risk for obstetric complications and secondary cases of psychosis was enhanced in relatives of patients with a history of obstetric complications. Siblings with obstetric complications had a low incidence of psychoses; therefore, obstetric complications could not explain the occurrence of secondary cases of psychosis in siblings. Patients with familial psychoses had a higher incidence of obstetric complications than did sporadic cases (without reaching statistical significance). There was no inverse relationship between the history of obstetric complications in patients and the morbid risk of first-degree relatives for psychoses. The familial versus sporadic distinction revealed no subgroups where obstetric complications were of special relevance.

Obstetric complications and physical size of offspring of schizophrenic, schizophrenic-like, and control mothers.

The question whether schizophrenic mothers have increased risk for obstetric complications (OCs) has practical relevance to fertility recommendations and obstetric surveillance for such women. From a theoretical viewpoint the study of OCs in schizophrenic women concerns the possible relationship between tension-anxiety and OCs, and, additionally, whether the offspring have an increased risk for disturbance based at least partially upon an increased incidence of OCs. Recent evidence suggests a relationship or interaction between genetic factors contributed through family lineage and OCs attending the gestation of genetically-high-risk offspring. Increased OC rates have been found to be differentially characteristic of the pre-schizophrenics or the pre-disturbed persons within discordant monozygotic twin pairs (27), discordant regular sibling pairs (23), and offspring of schizophrenic mothers (18). Mednick (15, p. 56) has suggested that the OCs ‘trigger some characteristic which may be genetically predisposed’.