Search

Key recommendations: An objective and validated index of nausea and vomiting such as the Pregnancy‐Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can be used to classify the severity of NVP and HG. [Grade C]Ketonuria is not an indicator of dehydration and should not be used to assess severity. [Grade A]There are safety and efficacy data for first line antiemetics such as anti (H1) histamines, phenothiazines and doxylamine/pyridoxine (Xonvea®) and they should be prescribed initially when required for NVP and HG (Appendix III). [Grade A]There is evidence that ondansetron is safe and effective. Its use as a second line antiemetic should not be discouraged if first line antiemetics are ineffective. Women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed HG. [Grade B]Metoclopramide is safe and effective and can be used alone or in combination with other antiemetics. [Grade B]Because of the risk of extrapyramidal effects metoclopramide should be used as second‐line therapy. Intravenous doses should be administered by slow bolus injection over at least 3 minutes to help minimise these. [Grade C]Women should be asked about previous adverse reactions to antiemetic therapies. If adverse reactions occur, there should be prompt cessation of the medications. [GPP]Normal saline (0.9% NaCl) with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, is the most appropriate intravenous hydration. [Grade C]Combinations of different drugs should be used in women who do not respond to a single antiemetic. Suggested antiemetics for UK use are given in Appendix III. [GPP]Thiamine supplementation (either oral 100 mg tds or intravenous as part of vitamin B complex (Pabrinex®)) should be given to all women admitted with vomiting, or severely reduced dietary intake, especially before administration of dextrose or parenteral nutrition. [Grade D]All therapeutic measures should have been tried before considering termination of pregnancy. [Grade C] [ABSTRACT FROM AUTHOR]

Background: There is a high prevalence of autoimmune conditions in women specially in the reproductive years; thus, the association with adverse pregnancy outcomes has been widely studied. However, few autoimmune conditions/adverse outcomes have been studied more than others, and this umbrella review aims to consolidate existing knowledge in this area with the aim to provide new knowledge and also identify gaps in this research area. Methods: Medline, Embase, and Cochrane databases were searched from inception to December 2023. Screening, data extraction, and quality appraisal (AMSTAR 2) were done by two independent reviewers. Data were synthesised narratively and quantitatively. Relative risks (RR)/odds ratio (OR) with 95% confidence intervals were reported. Results: Thirty-two reviews were included consisting of 709 primary studies. The review reported the association between 12 autoimmune conditions and 16 adverse pregnancy outcomes. Higher risk of miscarriage is reported in women with Sjögren's syndrome RR 8.85 (95% CI 3.10–25.26) and systemic lupus erythematosus (SLE) OR 4.90 (3.10–7.69). Pre-eclampsia was reported higher in women with type 1 diabetes mellitus (T1DM) OR 4.19 (3.08–5.71) and SLE OR 3.20 (2.54–4.20). Women reported higher risk of diabetes during pregnancy with inflammatory bowel disease (IBD) OR 2.96 (1.47–5.98). There was an increased risk of intrauterine growth restriction in women with systemic sclerosis OR 3.20 (2.21–4.53) and coeliac disease OR 1.71 (1.36–2.14). Preterm birth was associated with T1DM OR 4.36 (3.72–5.12) and SLE OR 2.79 (2.07–3.77). Low birth weight babies were reported in women with women with SLE or systemic sclerosis OR 5.95 (4.54–7.80) and OR 3.80 (2.16–6.56), respectively. There was a higher risk of stillbirth in women with T1DM OR 3.97 (3.44–4.58), IBD OR 1.57 (1.03–2.38), and coeliac disease OR 1.57 (1.17–2.10). T1DM in women was associated with 32% lower odds of small for gestational age baby OR 0.68 (0.56–0.83). Conclusions: Pregnant women with autoimmune conditions are at a greater risk of developing adverse pregnancy outcomes. Further research is required to develop better preconception to postnatal care for women with autoimmune conditions. [ABSTRACT FROM AUTHOR]

A study published in the journal Intensive Care Medicine examined the outcomes of women who were admitted to critical care during pregnancy or postpartum. The study found that women who were admitted to critical care had an increased risk of adverse short- and long-term maternal and neonatal outcomes compared to women who were not admitted to critical care. The most common reasons for admission were postpartum hemorrhage and pre-eclampsia. The study also found that neonates born to women admitted to critical care were more likely to require a higher level of neonatal care. The study highlights the need for better identification of women at risk and post-discharge follow-up to optimize their health and well-being. [Extracted from the article]

Background: Approximately one in ten women have high blood pressure during pregnancy. Hypertension is associated with adverse maternal and perinatal outcomes, and as treatment improves maternal outcomes, antihypertensive treatment is recommended. Previous trials have been unable to provide a definitive answer on which antihypertensive treatment is associated with optimal maternal and neonatal outcomes and the need for robust evidence evaluating maternal and infant benefits and risks remains an important, unanswered question for research and clinical communities. Methods: The Giant PANDA study is a pragmatic, open-label, multicentre, randomised controlled trial of a treatment initiation strategy with nifedipine (calcium channel blocker), versus labetalol (mixed alpha/beta blocker) in 2300 women with pregnancy hypertension. The primary objective is to evaluate if treatment with nifedipine compared to labetalol in women with pregnancy hypertension reduces severe maternal hypertension without increasing fetal or neonatal death or neonatal unit admission. Subgroup analyses will be undertaken by hypertension type (chronic, gestational, pre-eclampsia), diabetes (yes, no), singleton (yes, no), self-reported ethnicity (Black, all other), and gestational age at randomisation categories (11 + 0 to 19 + 6, 20 + 0 to 27 + 6, 28 + 0 to 34 + 6 weeks). A cost-effectiveness analysis using an NHS perspective will be undertaken using a cost-consequence analysis up to postnatal hospital discharge and an extrapolation exercise with a lifetime horizon conditional on the results of the cost-consequence analysis. Discussion: This trial aims to address the uncertainty of which antihypertensive treatment is associated with optimal maternal and neonatal outcomes. The trial results are intended to provide definitive evidence to inform guidelines and linked, shared decision-making tools, thus influencing clinical practice. Trial registration: EudraCT number: 2020–003410-12, ISRCTN: 12,792,616 registered on 18 November 2020. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity is common in women across the life course. Preterm birth is the single biggest cause of neonatal mortality and morbidity. We aim to estimate the prevalence of multimorbidity in pregnant women and to examine the association between maternal multimorbidity and PTB. Methods: This is a retrospective cohort study using electronic health records from the Scottish Morbidity Records. All pregnancies among women aged 15 to 49 with a conception date between 1 January 2014 and 31 December 2018 were included. Multimorbidity was defined as the presence of two or more pre-existing long-term physical or mental health conditions, and complex multimorbidity as the presence of four or more. It was calculated at the time of conception using a predefined list of 79 conditions published by the MuM-PreDiCT consortium. PTB was defined as babies born alive between 24 and less than 37 completed weeks of gestation. We used Generalised Estimating Equations adjusted for maternal age, socioeconomic status, number of previous pregnancies, BMI, and smoking history to estimate the effect of maternal pre-existing multimorbidity. Absolut rates are reported in the results and tables, whilst Odds Ratios (ORs) are adjusted (aOR). Results: Thirty thousand five hundred fifty-seven singleton births from 27,711 pregnant women were included in the analysis. The prevalence of pre-existing multimorbidity and complex multimorbidity was 16.8% (95% CI: 16.4–17.2) and 3.6% (95% CI: 3.3–3.8), respectively. The prevalence of multimorbidity in the youngest age group was 10.2%(95% CI: 8.8–11.6), while in those 40 to 44, it was 21.4% (95% CI: 18.4–24.4), and in the 45 to 49 age group, it was 20% (95% CI: 8.9–31.1). In women without multimorbidity, the prevalence of PTB was 6.7%; it was 11.6% in women with multimorbidity and 15.6% in women with complex multimorbidity. After adjusting for maternal age, socioeconomic status, number of previous pregnancies, Body Mass Index (BMI), and smoking, multimorbidity was associated with higher odds of PTB (aOR = 1.64, 95% CI: 1.48–1.82). Conclusions: Multimorbidity at the time of conception was present in one in six women and was associated with an increased risk of preterm birth. Multimorbidity presents a significant health burden to women and their offspring. Routine and comprehensive evaluation of women with multimorbidity before and during pregnancy is urgently needed. [ABSTRACT FROM AUTHOR]

The British Association of Dermatologists (BAD) has updated its clinical guideline for biologic therapy for psoriasis, including new treatments approved since the previous version. The guideline will now be a living guideline, updated as new evidence emerges. The decision aid for clinicians and patients has also been updated. The document provides information on different biologic treatments for psoriatic arthritis, including medication details, dosing frequency, approval dates, success rates, and potential side effects. It emphasizes that some treatments are recommended only after other options have failed and not all treatments are approved for psoriatic arthritis. The document is based on real-world data and aims to support clinical practice. [Extracted from the article]

Background: Heterogeneity in reported outcomes can limit the synthesis of research evidence. A core outcome set informs what outcomes are important and should be measured as a minimum in all future studies. We report the development of a core outcome set applicable to observational and interventional studies of pregnant women with multimorbidity. Methods: We developed the core outcome set in four stages: (i) a systematic literature search, (ii) three focus groups with UK stakeholders, (iii) two rounds of Delphi surveys with international stakeholders and (iv) two international virtual consensus meetings. Stakeholders included women with multimorbidity and experience of pregnancy in the last 5 years, or are planning a pregnancy, their partners, health or social care professionals and researchers. Study adverts were shared through stakeholder charities and organisations. Results: Twenty-six studies were included in the systematic literature search (2017 to 2021) reporting 185 outcomes. Thematic analysis of the focus groups added a further 28 outcomes. Two hundred and nine stakeholders completed the first Delphi survey. One hundred and sixteen stakeholders completed the second Delphi survey where 45 outcomes reached Consensus In (≥70% of all participants rating an outcome as Critically Important). Thirteen stakeholders reviewed 15 Borderline outcomes in the first consensus meeting and included seven additional outcomes. Seventeen stakeholders reviewed these 52 outcomes in a second consensus meeting, the threshold was ≥80% of all participants voting for inclusion. The final core outcome set included 11 outcomes. The five maternal outcomes were as follows: maternal death, severe maternal morbidity, change in existing long-term conditions (physical and mental), quality and experience of care and development of new mental health conditions. The six child outcomes were as follows: survival of baby, gestational age at birth, neurodevelopmental conditions/impairment, quality of life, birth weight and separation of baby from mother for health care needs. Conclusions: Multimorbidity in pregnancy is a new and complex clinical research area. Following a rigorous process, this complexity was meaningfully reduced to a core outcome set that balances the views of a diverse stakeholder group. [ABSTRACT FROM AUTHOR]

Background: Maternal multiple long-term conditions are associated with adverse outcomes for mother and child. We conducted a qualitative study to inform a core outcome set for studies of pregnant women with multiple long-term conditions. Methods: Women with two or more pre-existing long-term physical or mental health conditions, who had been pregnant in the last five years or planning a pregnancy, their partners and health care professionals were eligible. Recruitment was through social media, patients and health care professionals' organisations and personal contacts. Participants who contacted the study team were purposively sampled for maximum variation. Three virtual focus groups were conducted from December 2021 to March 2022 in the United Kingdom: (i) health care professionals (n = 8), (ii) women with multiple long-term conditions (n = 6), and (iii) women with multiple long-term conditions (n = 6) and partners (n = 2). There was representation from women with 20 different physical health conditions and four mental health conditions; health care professionals from obstetrics, obstetric/maternal medicine, midwifery, neonatology, perinatal psychiatry, and general practice. Participants were asked what outcomes should be reported in all studies of pregnant women with multiple long-term conditions. Inductive thematic analysis was conducted. Outcomes identified in the focus groups were mapped to those identified in a systematic literature search in the core outcome set development. Results: The focus groups identified 63 outcomes, including maternal (n = 43), children's (n = 16) and health care utilisation (n = 4) outcomes. Twenty-eight outcomes were new when mapped to the systematic literature search. Outcomes considered important were generally similar across stakeholder groups. Women emphasised outcomes related to care processes, such as information sharing when transitioning between health care teams and stages of pregnancy (continuity of care). Both women and partners wanted to be involved in care decisions and to feel informed of the risks to the pregnancy and baby. Health care professionals additionally prioritised non-clinical outcomes, including quality of life and financial implications for the women; and longer-term outcomes, such as children's developmental outcomes. Conclusions: The findings will inform the design of a core outcome set. Participants' experiences provided useful insights of how maternity care for pregnant women with multiple long-term conditions can be improved. [ABSTRACT FROM AUTHOR]

Vestibular migraine is a leading cause of vertigo in pregnancy and, although not a distinct migraine subtype, is an episodic syndrome associated with migraine. Vestibular migraine is associated with diverse symptoms such as vertigo, aura, allodynia, osmophobia, nausea, vomiting and tinnitus, many of which may be exacerbated by, masked or even dismissed in pregnancy. Vestibular migraine is likely an underdiagnosed and undertreated condition in pregnancy. The aetiology of vestibular migraine remains incompletely understood, although various theories have been proposed, including genetic predisposition, neurochemical dysregulation and pro-inflammatory mechanisms, all of which are derived from the pathophysiology of classical migraine. Physiologic changes to the endocrine, haematologic and vascular systems in pregnancy may affect pathophysiological processes in vestibular migraine, and can alter the course of symptoms experienced in pregnancy. These changes also predispose to secondary headache disorders, which may have similar presentations. There has been considerable progress in therapeutic advances in vestibular migraine prophylaxis and treatment outside of pregnancy. There is currently no significant evidence base for acute treatment or prophylaxis for pregnant patients, with treatment recommendations extrapolated from studies on classical migraine, and offered on a benefit versus risk basis. Challenges commonly encountered include difficulty establishing a diagnosis, in addition to recognising and treating neuropsychiatric and gestational co-morbidities. Anxiety, depression, hypertensive disorders and cardiovascular disease are closely associated with migraine, and important contributors to morbidity and mortality during pregnancy. Identifying and treating vestibular migraine during pregnancy offers a unique opportunity to impact future patient health through screening and early treatment of associated co-morbidities. There have been innovations in classical migraine therapy that may confer benefit in vestibular migraine in pregnancy, with emphasis on lifestyle modification, effective prophylaxis, abortive therapies, cognitive behaviour therapy and management of vestibular migraine-related comorbidities. [ABSTRACT FROM AUTHOR]

Neurologists increasingly use anti-CD20 therapies, including for women of childbearing age, despite these medications being unlicensed for use in pregnancy. Current evidence suggests that women can safely conceive while taking anti-CD20 therapy. Women should not be denied treatment during pregnancy when it is clinically indicated, although they should be counselled regarding live vaccinations for their infant. Women receiving regular ocrelizumab for multiple sclerosis should preferably wait 3 months before trying to conceive. There are few data around ofatumumab in pregnancy, and while there is probably a class effect across all anti-CD20 therapies, ofatumumab may need to be continued during pregnancy to maintain efficacy. We recommend that anti-CD20 therapies can be safely given while breast feeding. It is important to make time to discuss treatments with women of childbearing age to help them choose their most suitable treatment. Outcomes should be monitored in pregnancy registries. [ABSTRACT FROM AUTHOR]

While pregnancy is a time of relative immunosuppression, infective endocarditis and bacterial meningitis remain rare. We present a case of a pregnant woman with Streptococcus oralis endocarditis and meningitis. This is the first reported case of Streptococcus oralis meningitis in a patient without predisposing risk factors. This case highlights the importance of collecting blood cultures in febrile illness during pregnancy and illustrates that effective management plans can be formulated without performing invasive diagnostic tests such as transesophageal echocardiography. [ABSTRACT FROM AUTHOR]

Background: Chronic histiocytic intervillositis (CHI) is a rare placental lesion with a high recurrence rate and poor perinatal outcomes. There are currently limited guidelines regarding the diagnosis of this condition in the index pregnancy and treatment where recurrence is suspected. Objective: The primary objective of this systematic review and meta-analysis was to determine the perinatal outcomes of pregnancies affected by chronic histiocytic intervillositis and to what extent they can be improved with treatment. The secondary objective was to assess the relationship between CHI lesion severity and pregnancy loss. Methods: A systematic search of Ovid Embase, Web of Science, Science Direct, PubMed, Ovid Medline, Google Scholar and CINAHL was carried out. Case reports, cohort, case-control and randomised controlled trials (RCT) detailing the perinatal outcomes of CHI pregnancies, both treated and untreated, were included. Results: No RCTs were identified. However, in a review population of 659 pregnancies, with additional 7 in case reports, CHI treatments included aspirin, prednisone, prednisolone, low molecular weight heparin (LMWH), hydroxychloroquine and adalimumab. A descriptive synthesis of data found mixed results for treatments in relation to live birth, miscarriage and fetal growth restriction outcomes. Furthermore, quantitative synthesis of 38 pregnancies revealed a non-significant improvement in live birth rate with CHI targeted treatment (OR 1.79 [95% CI 0.33-9.61] (p=0.50), while meta-analysis of CHI severity in line with pregnancy loss, in a sample of 231 pregnancies, revealed lower odds of pregnancy loss with less severe lesions (OR: 0.17 [0.03-0.80], p=0.03). Conclusions: This systematic review and meta-analysis reinforce notions surrounding the insufficient evidence for CHI treatment. It also strengthens previous hypotheses detailing the positive association between CHI lesion severity and odds of pregnancy loss. Aspirin, LMWH, prednisolone, hydroxychloroquine and adalimumab are candidates with varying levels of weak to moderate evidence supporting their use. Further prospective research is required to obtain robust evidence pertaining to treatment safety and efficacy and optimal drug regimes. [ABSTRACT FROM AUTHOR]

Gastrointestinal cancer occurs in approximately 1 in 13,000 pregnancies, making up 4% of malignancies detected in pregnancy. It is a complex and challenging condition to diagnose and manage and is often only detected in its more advanced stages. This is partly due to symptoms of gastrointestinal cancer being incorrectly attributed to physiological symptoms of pregnancy, as well as concerns about the safety of diagnostic investigations in pregnancy, both of which may delay diagnosis and lead to disease progression. Challenges in management also arise from under-treatment in pregnancy due to concerns about the impact of surgery or chemotherapy on the pregnancy. We present here three cases of gastrointestinal cancer diagnosed in pregnancy in our centre and discuss the challenges and pitfalls one may encounter in the diagnosis and management of gastrointestinal malignancies in pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: Chronic inflammatory diseases (CIDs), including rheumatic diseases and other inflammatory conditions, often affect women of reproductive age. Tumor necrosis factor inhibitors (TNFi) are widely used to treat CID, but there is limited information on outcomes of TNFi-exposed pregnancies. We evaluated pregnancy outcomes from 1392 prospectively reported pregnancies exposed to certolizumab pegol (CZP), a PEGylated, Fc-free TNFi with no to minimal placental transfer. Methods: CZP-exposed pregnancies in patients with CID from the UCB Pharmacovigilance global safety database were reviewed from the start of CZP clinical development (July 2001) to 1 November 2020. To limit bias, the analysis focused on prospectively reported cases with known pregnancy outcomes. Results: In total, 1392 prospective pregnancies with maternal CZP exposure and known pregnancy outcomes (n = 1425) were reported; 1021 had at least first-trimester CZP exposure. Live birth was reported in 1259/1425 (88.4%) of all prospective outcomes. There were 150/1425 (10.5%) pregnancy losses before 20 weeks (miscarriage/induced abortion), 11/1425 (0.8%) stillbirths, and 5/1392 (0.4%) ectopic pregnancies. Congenital malformations were present in 30/1259 (2.4%) live-born infants, of which 26 (2.1%) were considered major according to the Metropolitan Atlanta Congenital Defects Program criteria. There was no pattern of congenital malformations. Discussion and conclusion: No signal for adverse pregnancy outcomes or congenital malformations was observed in CZP-exposed pregnancies. Although the limitations of data collected through this methodology (including underreporting, missing information, and absence of a comparator group) should be considered, these data provide reassurance for women with CID who require CZP treatment during pregnancy, and their treating physicians. [ABSTRACT FROM AUTHOR]

Background Contemporaneous data are required for women with chronic kidney disease (CKD) Stages 3–5 to inform pre-pregnancy counselling and institute appropriate antenatal surveillance. Methods A retrospective cohort study in women with CKD Stages 3–5 after 20 weeks' gestation was undertaken in six UK tertiary renal centres in the UK between 2003 and 2017. Factors predicting adverse outcomes and the impact of pregnancy in accelerating the need for renal replacement therapy (RRT) were assessed. Results There were 178 pregnancies in 159 women, including 43 women with renal transplants. The live birth rate was 98%, but 56% of babies were born preterm (before 37 weeks' gestation). Chronic hypertension was the strongest predictor of delivery before 34 weeks' gestation. Of 121 women with known pre-pregnancy hypertension status, the incidence of delivery before 34 weeks was 32% (31/96) in women with confirmed chronic hypertension compared with 0% (0/25) in normotensive women. The risk of delivery before 34 weeks doubled in women with chronic hypertension from 20% [95% confidence interval (CI) 9–36%] to 40% (95% CI 26–56%) if the gestational fall in serum creatinine was <10% of pre-pregnancy concentrations. Women with a urinary protein:creatinine ratio >100 mg/mmol prior to pregnancy or before 20 weeks' gestation had an increased risk for birthweight below the 10th centile (odds ratio 2.57, 95% CI 1.20–5.53). There was a measurable drop in estimated glomerular filtration rate (eGFR) between pre-pregnancy and post-partum values (4.5 mL/min/1.73 m2), which was greater than the annual decline in eGFR prior to pregnancy (1.8 mL/min/1.73 m2/year). The effect of pregnancy was, therefore, equivalent to 1.7, 2.1 and 4.9 years of pre-pregnancy renal disease in CKD Stages 3a, 3b and 4–5, respectively. The pregnancy-associated decline in renal function was greater in women with chronic hypertension and in those with a gestational fall in serum creatinine of <10% of pre-pregnancy concentrations. At 1 year post-partum, 46% (58/126) of women had lost ≥25% of their pre-pregnancy eGFR or required RRT. Most women with renal transplants had CKD Stage 3 and more stable renal function prior to pregnancy. Renal transplantation was not independently associated with adverse obstetric or renal outcomes. Conclusions Contemporary pregnancies in women with CKD Stages 3–5 are complicated by preterm delivery, low birthweight and loss of maternal renal function. Chronic hypertension, pre- or early pregnancy proteinuria and a gestational fall in serum creatinine of <10% of pre-pregnancy values are more important predictors of adverse obstetric and renal outcome than CKD Stages 3–5. Pregnancy in women with CKD Stages 3–5 advances the need for dialysis or transplantation by 2.5 years. [ABSTRACT FROM AUTHOR]

Simultaneous pancreas and kidney (SPK) transplantation, in uremic women with insulin‐dependent diabetes, increases the chance of a successful pregnancy and minimizes the risk to infants. The aim of this study was to document pregnancy and explore the challenges in this cohort of women. Retrospective analysis of women who underwent pancreas transplantation between January 1, 1998 and 8 January, 2019 was conducted. Seventeen pregnancies were identified in 13 women. Mean transplant‐to‐pregnancy interval was 4.6 years (range, 1.1–10.2 years). Eleven pregnancies resulted in live birth (65%), and six (35%) ended in miscarriage/fetal loss at a median gestational age of 8.5 weeks. Mean gestational age at delivery was 34.9 weeks (SD ±3 weeks). Preeclampsia and C‐section rates were 77% and 67%, respectively. Adverse fetal and graft outcomes were observed in 100% of unplanned pregnancies, compared to 10% of planned pregnancies (P <.001). One kidney allograft was lost during pregnancy; one pancreas and two kidney allografts were lost within 3 years of pregnancy. This is a high‐risk group for grafts and offspring. Pre‐pregnancy planning is vital. A multidisciplinary approach by obstetric and transplant teams is important pre‐pregnancy, antenatally, and peripartum. This is the largest published series of pregnancies in SPK recipients from a single center. [ABSTRACT FROM AUTHOR]

Background Serum anti-Müllerian hormone (AMH) is a biomarker of ovarian reserve. There are limited data to guide the clinical interpretation of AMH in women with chronic kidney disease (CKD). The purpose of this study was to examine AMH concentrations in women with CKD compared with women without CKD. Methods We conducted a prospective cohort study of serum AMH concentrations in 163 non-pregnant women with CKD. Serum AMH concentrations were compared with age-specific AMH centiles from 887 healthy female controls. Results Participants included 30 women with Stage 1 CKD, 37 women with Stage 2 CKD, 26 women with Stage 3a CKD, 31 women with Stage 3b CKD and 39 women with Stages 4 and 5 CKD. The median estimated glomerular filtration rate (eGFR) was 51 (interquartile range 31–80) mL/min/1.73 m2. Serum AMH concentrations were lower in all CKD stages compared with women without CKD. Women ages 20–24 years with CKD had comparable serum AMH concentrations (median 1.959 ng/mL) to women ages 35–39 years without CKD (median 1.995 ng/mL). There was no evidence that eGFR was an independent modifier of serum AMH concentrations. More than half of women with CKD (58%) were predicted to have a low response to gonadotrophin stimulation. Conclusions Women with CKD have a lower ovarian reserve and are predicted to have a lower ovarian response to gonadotrophin stimulation compared with women without CKD of a similar age. Women with CKD who fail to conceive within 6 months of regular unprotected intercourse should be considered for fertility assessment and intervention. [ABSTRACT FROM AUTHOR]

Background and Objective: There is an urgent need for robust data on the trajectories and outcomes of pregnancies in women with inflammatory rheumatic diseases (IRD). In particular when rare outcomes or rare diseases are to be investigated, collaborative approaches are required. However, joint data analyses are often limited by the heterogeneity of the different data sources.To facilitate future research collaboration, a European League Against Rheumatism (EULAR) Task Force defined a core data set with a minimum of items to be collected by pregnancy registries in rheumatology covering the period of pregnancy and the 28-day neonatal phase in women with any underlying IRD.Methods: A stepwise process included a two-round Delphi survey and a face-to-face meeting to achieve consensus about relevant items.Results: A total of 64 multidisciplinary stakeholders from 14 different countries participated in the two rounds of the Delphi process. During the following face-to-face meeting of the EULAR Task Force, consensus was reached on 51 main items covering 'maternal information', 'pregnancy' and 'treatment'. Generic instruments for assessment are recommended for every item. Furthermore, for the five most frequent IRDs rheumatoid arthritis, spondyloarthritis, juvenile idiopathic arthritis, systemic lupus erythematosus and other connective tissue diseases, disease-specific laboratory markers and disease activity measurements are proposed.Conclusion: This is the first consensus-based core data set for prospective pregnancy registries in rheumatology. Its purpose is to stimulate and facilitate multinational collaborations that aim to increase the knowledge about pregnancy course and safety of treatment in women with IRDs during pregnancy. [ABSTRACT FROM AUTHOR]

Objective: Recent studies suggest that combinations of clinical probability assessment (the YEARS algorithm or Geneva score) and D-dimer can safely rule out suspected pulmonary embolism (PE) in pregnant women. We performed a secondary analysis of the DiPEP (Diagnosis of Pulmonary Embolism in Pregnancy) study data to determine the diagnostic accuracy of these strategies.Methods: The DiPEP study prospectively recruited and collected data and blood samples from pregnant/postpartum women with suspected PE across 11 hospitals and retrospectively collected data from pregnant/postpartum women with diagnosed PE across all UK hospitals (15 February 2015 to 31 August 2016). We selected prospectively recruited pregnant women who had definitive diagnostic imaging for this analysis. We used clinical data and D-dimer results to determine whether the rule out strategies would recommend further investigation. Two independent adjudicators used data from imaging reports, treatments and adverse events up to 30 days to determine the reference standard.Results: PEs were diagnosed in 12/219 (5.5%) women. The YEARS/D-dimer strategy would have ruled out PE in 96/219 (43.8%) but this would have included 5 of the 12 with PEs. Sensitivity for PE was 58.3% (95% CI 28.6% to 83.5%) and specificity 44.0% (37.1% to 51.0%). The Geneva/D-dimer strategy would have ruled out PE in 46/219 (21.0%) but this would have included three of the 12 with PE. Sensitivity was 75.0% (95% CI 42.8% to 93.3%) and specificity 20.8% (95% CI 15.6% to 27.1%). Administration of anticoagulants prior to blood sampling may have reduced D-dimer sensitivity for small PE.Conclusion: Strategies using clinical probability and D-dimer have limited diagnostic accuracy and do not accurately rule out all PE in pregnancy. It is uncertain whether PE missed by these strategies lead to clinically important consequences. [ABSTRACT FROM AUTHOR]

Background: Evidence for risks of adverse maternal and birth outcomes in women with hyperemesis gravidarum (HG) is predominantly from small studies, unknown, or conflicting.Methods: A population-based cohort study using secondary health care records (Hospital Episode Statistics covering all of England from 1997 to 2012) was used to calculate odds ratios (OR) with 99% confidence intervals (CI) for the association between HG hospital admission and adverse outcomes, adjusting for maternal and pregnancy confounders.Results: Within 8 211 850 pregnancies ending in live births or stillbirths, women with HG had increased odds of anaemia (OR 1.28, 99% CI 1.23, 1.33), preeclampsia (OR 1.16, 99% CI 1.09, 1.22), eclampsia (OR 1.84, 99% CI 1.07, 3.18), venous thromboembolism antenatally (OR 1.94, 99% CI 1.57, 2.39 for deep vein thrombosis, and OR 2.54, 99% CI 1.89, 3.40 for pulmonary embolism) and post-partum. Odds of stillbirth (OR 0.77, 99% CI 0.66, 0.89) and post-term (OR 0.86, 99% CI 0.81, 0.92) delivery were decreased. Women were more likely to be induced (OR 1.20, 99% CI 1.16, 1.23), to deliver preterm (OR 1.11, 99% CI 1.05, 1.17), very preterm (OR 1.18, 99% CI 1.05, 1.32), or by caesarean section (OR 1.12, 99% CI 1.08, 1.16), to have low birthweight (OR 1.12, 99% CI 1.08, 1.17) or small for gestational age (OR 1.06, 99% CI 1.01, 1.11) babies and although absolute risks were small, their offspring were more likely to undergo resuscitation or neonatal intensive care.Conclusion: HG may have important antenatal and postnatal consequences that should be considered in communications between health care professionals and women to best manage HG and prevent progression during pregnancy. [ABSTRACT FROM AUTHOR]

These risks are particularly relevant for women with CKD with co-existing chronic hypertension and those known to be at increased risk of vascular disease, venous thromboembolism (due to anti-phospholipid antibodies or nephrotic syndrome), or cervical neoplasia in the context of immunosuppression. A meta-analysis that compared 2682 pregnancies in women with CKD with 26,149 pregnancies in healthy controls showed that weighted averages of adverse maternal events in women with CKD and healthy controls were 11.5 and 2% respectively, with a two-fold increase in adverse neonatal outcomes (premature births, fetal growth restriction, small for gestational age, neonatal mortality, stillbirths, and low birth weight) in women with CKD [[101]]. However the guideline committee recommend expert, multidisciplinary pre-pregnancy counselling for women with an eGFR < 60 ml/min/1.73m SP 2 sp , women with CKD progression, women with uncontrolled hypertension (> 140/90 mmHg), women with nephrotic-range proteinuria, women with active renal disease, women with lupus nephritis, women with renal transplants and all women with previous adverse obstetric outcomes. Although longitudinal patient data are not available to confirm that disease stabilisation improves pregnancy outcomes, the aim of disease quiescence prior to conception is recommended. In the absence of evidence specific to women with CKD, and given the potential cardiovascular sequelae of a positive calcium balance in women with CKD [[149]], it was the consensus opinion of the guideline committee that calcium supplementation to reduce the risk of pre-eclampsia cannot be recommended for women with CKD, based on current evidence. [Extracted from the article]

Context The risks of primary hyperparathyroidism (pHPT) to pregnant women and their fetuses appear to increase commensurate with serum calcium levels. The management strategy for pHPT must be adapted in pregnancy and should reflect the severity of hypercalcemia. However, no guidelines exist to assist clinicians. Methods The experience of a high-volume multidisciplinary endocrine surgical service in treating a consecutive series of pregnant women with pHPT referred for parathyroidectomy is presented and data are compared with a nonpregnant cohort with pHPT. A review of pHPT and pregnancy outcomes in the literature is provided. Results Seventeen pregnant women and 247 age range–matched nonpregnant women with pHPT were referred for surgery over 11 years. Mean serum calcium level was higher in the pregnant cohort (2.89 vs 2.78 mmol/L; P = 0.03). Preoperative localization with ultrasound succeeded in eight pregnant women (47%) and sestamibi scanning did in two of six (33% imaged preconception), compared with 84 (34%) and 102 (42%) control subjects, respectively (not significant). Parathyroidectomy was performed under general anesthesia between 12 and 28 weeks' gestation with no adverse pregnancy outcomes resulting. Cure rate was 100% vs 96% in controls. Conclusion pHPT in pregnancy is a threat to mother and child. Medical management may be appropriate in mild disease, but in moderate to severe disease, parathyroidectomy under general anesthesia in the second trimester is safe. Localization using ionizing radiation/MRI is unnecessary, because surgical intervention in a high-volume multidisciplinary setting has excellent outcomes. Guidelines on the topic would assist clinicians. [ABSTRACT FROM AUTHOR]

Multiple sclerosis (MS) is more common in women than men and is most commonly diagnosed in early adulthood; thus, many patients will not have completed their families at the time of diagnosis. There is increasing awareness of the importance of early treatment in preventing long-term disability in MS. Delaying treatment until women with MS have completed their families can lead to the development of irreversible disability in at least some cases. It is therefore important to discuss family planning and pregnancy proactively. However, to date there is limited evidence to inform such discussions. We set out to develop consensus guidelines for the treatment of MS in pregnancy to encourage and facilitate discussions in this important area. The guidelines draw on available evidence from drug-specific pregnancy registers and published literature and have been scored by a panel of experts from a variety of disciplines using modified Delphi criteria. They cover prepregnancy counselling, management during pregnancy, delivery and anaesthetic options, postpartum advice and specific advice regarding currently licensed disease-modifying drugs. As the complexity and range of available disease-modifying drugs increase, further data gathering via a UK-wide MS pregnancy register is recommended. [ABSTRACT FROM AUTHOR]

The maternal population in the UK has become an increasingly challenging group of patients to manage. Women with pre-existing and often complex medical conditions are successfully conceiving. Most physicians will have had some involvement in the care of obstetric patients admitted with medical problems, and a lack of experience and fear of causing harm may result in essential investigations and treatment being withheld. The physiological changes in pregnancy can complicate the interpretation of observations and test results. This article discusses the presentation of commonly encountered medical problems in the obstetric population, including breathlessness, chest pain, palpitations, seizure and headache. It covers specific investigations and suggested treatment in this subset of patients. These women should receive the same level of care and attention as those who are not pregnant. Early diagnosis and effective management can help to reduce maternal morbidity and mortality caused by medical problems arising during pregnancy. [ABSTRACT FROM AUTHOR]

Black ethnicity is associated with worse pregnancy outcomes in women with chronic hypertension. Preexisting endothelial and renal dysfunction and poor placentation may contribute, but pathophysiological mechanisms under- pinning increased risk are poorly understood. This cohort study aimed to investigate the relationship between ethnicity, superimposed pre-eclampsia, and longitudinal changes in markers of endothelial, renal, and placental dysfunction in women with chronic hypertension. Plasma concentrations of placental growth factor (PlGF), syndecan-1, renin, and aldosterone and urinary angiotensinogen-to-creatinine ratio (AGTCR), protein-to-creatinine ratio (PCR), and albumin-to-creatinine ratio (ACR) were quantified during pregnancy and postpartum in women with chronic hypertension. Comparisons of longitudinal biomarker concentrations were made using log-transformation and random effects logistic regression allowing for gestation. Of 117 women, superimposed preeclampsia was diagnosed in 21% (n = 25), with 24% (n = 6) having an additional diagnosis of diabetes. The cohort included 63 (54%) women who self-identified as being of black ethnicity. PlGF concentrations were 67% lower [95% confidence interval (CI) -79 to -48%] and AGTCR, PCR, and ACR were higher over gestation, in women with subsequent superimposed preeclampsia (compared with those without superimposed preeclampsia). PlGF 100 pg/ml at 20-23.9 wk of gestation predicted subsequent birth weight 3rd percentile with 88% sensitivity (95% CI 47-100%) and 83% specificity (95% CI 70-92%). Black women had 43% lower renin (95% CI -58 to -23%) and 41% lower aldosterone (95%CI -45 to -15%) concentrations over gestation. Changes in placental (PlGF) and renal (AGTCR/PCR/ACR) biomarkers predated adverse pregnancy outcome. Ethnic variation in the renin-angiotensin-aldosterone system exists in women with chronic hypertension in pregnancy and may be important in treatment selection. [ABSTRACT FROM AUTHOR]

Key content: Postural tachycardia syndrome (PoTS) is a potentially debilitating autonomic disturbance that primarily affects females between the ages of 15 and 50 years, and may present for the first time during pregnancy. The typical signs and symptoms are vague and therefore the condition is often under‐ or misdiagnosed as pregnancy may induce similar symptoms. If correctly diagnosed and managed, patients have a good outcome; however, a delay in diagnosis may be disabling. PoTS is unfamiliar to most clinicians and its variable course during pregnancy requires a better understanding of the condition. PoTS management in pregnancy may be challenging and clinicians should be aware of common strategies that are suitable in pregnancy. A multidisciplinary approach is essential for correctly diagnosing and managing the condition and optimising pregnancy outcomes. Learning objectives: To understand: The common symptoms and signs of PoTS. How to diagnose and manage PoTS safely in pregnancy. The likely course of disease in pregnant women with PoTS. The effect of pregnancy on PoTS. Multidisciplinary antenatal, intrapartum and postnatal considerations required for patients with PoTS. Ethical issues: The impact of delayed diagnosis on individuals. The safety of commonly used pharmaceutical agents. The role of psychological support. [ABSTRACT FROM AUTHOR]

Objective To investigate the mechanisms that link maternal haemoglobin concentration with stillbirth. Design A retrospective cohort analysis using anonymised maternity data from two hospitals in England. Setting The Royal Wolverhampton NHS Trust and Guy's and St Thomas' NHS Foundation Trust. Study population 12 636 women with singleton pregnancies =24 weeks of gestation giving birth in the two hospitals during 2013-2015. Method A conceptual framework of hypothesised pathways through birth weight-for-gestational age and maternal infection including potential confounders and other risk factors was developed and examined using path-analysis. Path-analysis was performed by fitting a set of regression equations using weighted least squares adjusted for mean and variance. Goodness-of-fit indices were estimated. Main outcome measures Coefficient of association (β) for relationship between each parameter, and direct, indirect and total effects via the postulated pathways. Results The path-model showed a significant adjusted indirect negative effect of maternal haemoglobin on stillbirth mediated via birth weight-for-gestational age (standardised estimate (SE)=-0.01; 95% CI=-0.01 to -0.001; P=0.028). The effect through maternal infection was not significant at P<0.05 (SE=0.001; 95% CI=-0.004 to 0.01; P=0.610). There was a residual direct negative effect of maternal haemoglobin on stillbirth (SE=-0.12; 95% CI -0.23 to -0.02; P=0.020) after accounting for the two pathways. Total indirect SE=-0.004; 95% CI -0.01 to 0.003; P=0.267; total direct and indirect SE=-0.13; 95% CI -0.23 to -0.02; P=0.016. The goodness-of-fit indices showed a good fit between the model and the data. Conclusion While some of the influence on risk of stillbirth acts through low birth weight-for-gestational age, the majority does not. Several new mechanisms have been suggested for how haemoglobin may be exerting its influence on the risk of stillbirth possibly involving genetic, epigenetic and/or alternative obstetric and nutritional pathologies, but much more research is needed. [ABSTRACT FROM AUTHOR]

A 34-year-old woman presented at 29 weeks gestation of a twin pregnancy, with a platelet count of 1 × 109/l. She was extensively investigated and was subsequently diagnosed with severe immune thrombocytopenia. She did not respond to initial treatment with corticosteroids and intravenous immunoglobulin. She also failed to respond to second-line therapies of Anti-D immunoglobulin, Azathioprine and the thrombopoietin agonist Romiplostim. Her case was further complicated by an episode of obstetric cholestasis possibly related to Azathioprine treatment. She went on to require plasma exchange around the time of an elective Caesarean section which provided temporary improvement in the platelet count and enabled safe delivery. This case highlights some of the challenges faced in the management of patients with severe and refractory immune thrombocytopenia during pregnancy. [ABSTRACT FROM AUTHOR]

This study aimed to estimate the diagnostic utility of biomarkers for suspected venous thromboembolism (VTE) in pregnancy and the puerperium. Research nurses/midwives collected blood samples from 310 pregnant/postpartum women with suspected pulmonary emboli (PE) and 18 with diagnosed deep vein thrombosis (DVT). VTE was diagnosed using imaging, treatment and adverse outcome data. Primary analysis was limited to women with conclusive imaging (36 with VTE, 247 without). The area under the curve (AUC) for each biomarker was: activated partial thromboplastin time 0.669 (95% confidence interval 0.570-0.768), B-type natriuretic peptide 0.549 (0.453-0.645), C-reactive protein 0.542 (0.445-0.639), Clauss fibrinogen 0.589 (0.476-0.701), D-Dimer (by enzyme-linked immunosorbent assay) 0.668 (0.561-0.776), near-patient D-Dimer 0.651 (0.545-0.758), mid-regional pro-atrial natriuretic peptide 0.524 (0.418-0.630), prothrombin fragment 1 + 2 0.562 (0.462-0.661), plasmin-antiplasmin complexes 0.639 (0.536-0.742), prothombin time 0.613 (0.508-0.718), thrombin generation lag time 0.702 (0.598-0.806), thrombin generation endogenous potential 0.559 (0.437-0.681), thrombin generation peak 0.596 (0.478-0.715), thrombin generation time to peak 0.655 (0.541-0.769), soluble tissue factor 0.531 (0.424-0.638) and serum troponin 0.597 (0.499-0.695). No diagnostically useful threshold for diagnosing or ruling out VTE was identified. In pregnancy and the puerperium, conventional and candidate biomarkers have no utility either for their negative or positive predictive value in the diagnosis of VTE. [ABSTRACT FROM AUTHOR]

Key content: The importance of effective contraception in women with cardiac disease is discussed. Circulatory changes in pregnancy can cause unmasking and decompensation of pre‐existing cardiac disease. Information is provided for obstetricians, cardiologists and other healthcare professionals that will enable them to counsel women with cardiac disease appropriately about contraceptive options. Learning objectives: To appreciate the physiological changes that occur during pregnancy and why this can lead to decompensated heart disease. To gain an understanding of the most appropriate contraceptive methods for women with cardiac disease. To appreciate the cautions and contraindications for commonly used contraceptives in women with cardiac disease. [ABSTRACT FROM AUTHOR]

Background: Despite numerous publications stating the importance of multidisciplinary care for women with pre-existing medical conditions, there is a lack of evidence regarding structure or processes of multidisciplinary working, nor impact on maternal or infant outcomes. This study aimed to evaluate the implementation of guidelines for multidisciplinary team (MDT) management in pregnant women with pre-existing diabetes or cardiac conditions. These conditions were selected as exemplars of increasingly common medical conditions in pregnancy for which MDT management is recommended to prevent or reduce adverse maternal and fetal outcomes.Methods: National on-line survey sent to clinicians responsible for management or referral of women with pre-existing diabetes or cardiac conditions in UK National Health Service (NHS) maternity units. The survey comprised questions regarding the organisation of MDT management for women with pre-existing diabetes or cardiac conditions. Content was informed by national guidance.Results: One hundred seventy-nine responses were received, covering all health regions in England (162 responses) and 17 responses from Scotland, Wales and Northern Ireland. 132 (74%) related to women with diabetes and 123 (69%) to women with cardiac conditions. MDT referral was reportedly standard practice in most hospitals, particularly for women with pre-existing diabetes (88% of responses vs. 63% for cardiac) but there was wide variation in relation to MDT membership, timing of referral and working practices. These inconsistencies were evident within and between maternity units across the UK. Reported membership was medically dominated and often in the absence of midwifery/nursing and other allied health professionals. Less than half of MDTs for women with diabetes met the recommendations for membership in national guidance, and although two thirds of MDTs for women with cardiac disease met the core recommendations for membership, most did not report having the extended members: midwives, neonatologists or intensivists.Conclusions: The wide diversity of organisational management for women with pre-existing diabetes or cardiac conditions is of concern and merits more detailed inquiry. Evidence is also required to support and better define the recommendations for MDT care. [ABSTRACT FROM AUTHOR]

Interstitial lung disease (ILD) is an inflammatory and fibrotic infiltrative process of the lung that is often associated with collagen vascular disease in women. Untreated, it results in collagen deposition in the lung interstitium that can lead to a slow suffocating death. Pregnancy planning is often not discussed with women who have ILD due to concerns about potentially aggravating the disease process, or due to lack of knowledge about the safety of medications used to treat ILD. With improved understanding of the pathophysiology of both autoimmune disease and ILD, it has become clear that safe, planned pregnancies are possible in most women with ILD. In this article, our aim is to review diagnosis, treatment, and disease course of ILD in women who are planning a pregnancy or are pregnant. Better understanding of the disease process and knowledge of safe treatments will likely lead to improved pregnancy planning in women with ILD. [ABSTRACT FROM AUTHOR]

Systemic lupus erythematosus (SLE) is a chronic, multisystem autoimmune disease predominantly affecting women, particularly those of childbearing age. SLE provides challenges in the prepregnancy, antenatal, intrapartum, and postpartum periods for these women, and for the medical, obstetric, and midwifery teams who provide their care. As with many medical conditions in pregnancy, the best maternal and fetal-neonatal outcomes are obtained with a planned pregnancy and a cohesive multidisciplinary approach. Effective prepregnancy risk assessment and counseling includes exploration of factors for poor pregnancy outcome, discussion of risks, and appropriate planning for pregnancy, with consideration of discussion of relative contraindications to pregnancy. In pregnancy, early referral for hospital-coordinated care, involvement of obstetricians and rheumatologists (and other specialists as required), an individual management plan, regular reviews, and early recognition of flares and complications are all important. Women are at risk of lupus flares, worsening renal impairment, onset of or worsening hypertension, preeclampsia, and/or venous thromboembolism, and miscarriage, intrauterine growth restriction, preterm delivery, and/or neonatal lupus syndrome (congenital heart block or neonatal lupus erythematosus). A cesarean section may be required in certain obstetric contexts (such as urgent preterm delivery for maternal and/or fetal well-being), but vaginal birth should be the aim for the majority of women. Postnatally, an ongoing individual management plan remains important, with neonatal management where necessary and rheumatology followup. This article explores the challenges at each stage of pregnancy, discusses the effect of SLE on pregnancy and vice versa, and reviews antirheumatic medications with the latest guidance about their use and safety in pregnancy. Such information is required to effectively and safely manage each stage of pregnancy in women with SLE. [ABSTRACT FROM AUTHOR]