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
Summary
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.
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.
...family planning physicians may be over-cautious, denying women appropriate contraception, thus leading to unplanned pregnancies. 2 Similarly, cardiologists may be unaware of the range of effective ...and safe contraceptive methods so that patients with the highest risk lesions may not have access to effective contraception and have unintended, high risk pregnancies. The failure rate is also higher when performed at the time of caesarean section. 16 Risks of contraception and pregnancy in heart disease: key points Cardiac disease is a leading cause of maternal death in the UK For women with heart disease: pregnancy may be life threatening there is a safe and effective method of contraception for each condition Cardiologists need to: understand the risks of pregnancy in women with heart disease appreciate the need to refer high risk women for specialist pre-pregnancy counselling and antenatal care offer appropriate contraceptive advice Laparoscopic sterilisation requires insufflation of the abdomen with carbon dioxide, intermittent head down tilt and positive pressure ventilation, all of which combine to reduce cardiac output and may be poorly tolerated by those with a Fontan circulation or pulmonary vascular disease.
Physiological changes in pregnancy Soma-Pillay, Priya; Nelson-Piercy, Catherine; Tolppanen, Heli ...
Cardiovascular Journal of Africa,
03/2016, Letnik:
27, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Physiological changes occur in pregnancy to nurture the developing foetus and prepare the mother for labour and delivery. Some of these changes influence normal biochemical values while others may ...mimic symptoms of medical disease. It is important to differentiate between normal physiological changes and disease pathology. This review highlights the important changes that take place during normal pregnancy.
Chronic hypertension complicates around 3% of all pregnancies. There is evidence that treating severe hypertension reduces maternal morbidity. This study aimed to systematically review randomized ...controlled trials of antihypertensive agents treating chronic hypertension in pregnancy to determine the effect of this intervention.
Medline (via OVID), Embase (via OVID) and the Cochrane Trials Register were searched from their earliest entries until November 30, 2016. All randomized controlled trials evaluating antihypertensive treatments for chronic hypertension in pregnancy were included. Data were extracted and analyzed in Stata (version 14.1). Fifteen randomized controlled trials (1166 women) were identified for meta-analysis. A clinically important reduction in the incidence of severe hypertension was seen with antihypertensive treatment versus no antihypertensive treatment/placebo (5 studies, 446 women; risk ratio 0.33, 95%CI 0.19-0.56; I
0.0%). There was no difference in the incidence of superimposed pre-eclampsia (7 studies, 727 women; risk ratio 0.74, 95%CI 0.49-1.11; I
28.1%), stillbirth/neonatal death (4 studies, 667 women; risk ratio 0.37, 95%CI 0.11-1.26; I
0.0%), birth weight (7 studies, 802 women; weighted mean difference -60 g, 95%CI -200 to 80 g; I
0.0%), or small for gestational age (4 studies, 369 women; risk ratio 1.01, 95%CI 0.53-1.94; I
0.0%) with antihypertensive treatment versus no treatment/placebo.
Antihypertensive treatment reduces the risk of severe hypertension in pregnant women with chronic hypertension. A considerable paucity of data exists to guide choice of antihypertensive agent. Adequately powered head-to-head randomized controlled trials of commonly used antihypertensive agents are required to inform prescribing.
Summary
Knowledge of the absolute and relative risk of venous thromboembolism (VTE) in and around pregnancy would be crucial in identifying when to commence and cease thromboprophylaxis in women who ...would benefit from such intervention. We addressed this hypothesis using a large prospective primary care database from the United Kingdom, containing details on 972 683 women aged 15–44 years between 1987 and 2004. Risks of a first VTE during antepartum, postpartum and outside of pregnancy were compared using Poisson regression. The rate of VTE during the third trimester antepartum was six times higher than time outside pregnancy Incidence Rate Ratio (IRR) = 6·1; 95% confidence interval, 4·7–7·9. In contrast, both the first (IRR = 1·6) and second (IRR = 2·1) trimesters conferred little increase in risk. The first 6 weeks postpartum was associated with a 22‐fold increase in risk, with the peak occurring in the first 3 weeks. Increased age was found to be associated with VTE during postpartum and outside of pregnancy, but not during antepartum. Our findings of a notably raised risk of VTE persisting for 3 weeks postpartum and of a raised antepartum risk constrained to the third trimester have implications for modifying the current recommendations for VTE prophylaxis in pregnancy and the puerperium.
A European League Against Rheumatism (EULAR) task force was established to define points to consider on use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Based on a ...systematic literature review and pregnancy exposure data from several registries, statements on the compatibility of antirheumatic drugs during pregnancy and lactation were developed. The level of agreement among experts in regard to statements and propositions of use in clinical practice was established by Delphi voting. The task force defined 4 overarching principles and 11 points to consider for use of antirheumatic drugs during pregnancy and lactation. Compatibility with pregnancy and lactation was found for antimalarials, sulfasalazine, azathioprine, ciclosporin, tacrolimus, colchicine, intravenous immunoglobulin and glucocorticoids. Methotrexate, mycophenolate mofetil and cyclophosphamide require discontinuation before conception due to proven teratogenicity. Insufficient documentation in regard to fetal safety implies the discontinuation of leflunomide, tofacitinib as well as abatacept, rituximab, belimumab, tocilizumab, ustekinumab and anakinra before a planned pregnancy. Among biologics tumour necrosis factor inhibitors are best studied and appear reasonably safe with first and second trimester use. Restrictions in use apply for the few proven teratogenic drugs and the large proportion of medications for which insufficient safety data for the fetus/child are available. Effective drug treatment of active inflammatory rheumatic disease is possible with reasonable safety for the fetus/child during pregnancy and lactation. The dissemination of the data to health professionals and patients as well as their implementation into clinical practice may help to improve the management of pregnant and lactating patients with rheumatic disease.
Pregnant women may have an increased risk of stroke compared with nonpregnant women of similar age, but the magnitude and the timing of such risk are unclear. We examined the risk of a first stroke ...event in women of childbearing age and compared the risk during pregnancy and in the early postpartum period with the background risk outside these periods.
We conducted an open cohort study of 2 046 048 women aged 15 to 49 years between April 1, 1997, and March 31, 2014, using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode Statistics) care records in England. Risk of first stroke was assessed by calculating the incidence rate of stroke in antepartum, peripartum (2 days before until 1 day after delivery), and early (first 6 weeks) and late (second 6 weeks) postpartum periods compared with nonpregnant time using a Poisson regression model with adjustment for maternal age, socioeconomic group, and calendar time. A total of 2511 women had a first stroke. The incidence rate of stroke was 25.0 per 100 000 person-years (95% CI 24.0-26.0) in nonpregnant time. The rate was lower antepartum (10.7 per 100 000 person-years, 95% CI 7.6-15.1) but 9-fold higher peripartum (161.1 per 100 000 person-years, 95% CI 80.6-322.1) and 3-fold higher early postpartum (47.1 per 100 000 person-years, 95% CI 31.3-70.9). Rates of ischemic and hemorrhagic stroke both increased peripartum and early postpartum.
Although the absolute risk of first stroke is low in women of childbearing age, healthcare professionals should be aware of a considerable increase in relative risk during the peripartum and early postpartum periods.
Aims
Prescribing drug treatment for the management of hyperemesis gravidarum (HG), the most severe form of nausea and vomiting in pregnancy, remains controversial. Since most manufacturers do not ...recommend prescribing antiemetics during pregnancy, little is known regarding which treatments are most prevalent among pregnant patients. Here, we report for the first time, evidence of actual treatments prescribed in English hospitals.
Methods
A retrospective pregnancy cohort was constructed using anonymised electronic records in the Nottingham University Hospitals Trust system for all women who delivered between January 2010 and February 2015. For women admitted to hospital for HG, medications prescribed on discharge were described and variation by maternal characteristics was assessed. Compliance with local and national HG treatment guidelines was evaluated.
Results
Of 33 567 pregnancies (among 30 439 women), the prevalence of HG was 1.7%. Among 530 HG admissions with records of discharge drugs, cyclizine was the most frequently prescribed (almost 73% of admissions). Prochlorperazine and metoclopramide were prescribed mainly in combination with other drugs; however, ondansetron was more common than metoclopramide at discharge from first and subsequent admissions. Steroids were only prescribed following readmissions. Thiamine was most frequently prescribed following readmission while high dose of folic acid was prescribed equally after first or subsequent admissions. Prescribing showed little variation by maternal age, ethnicity, weight, socioeconomic deprivation, or comorbidities.
Conclusion
Evidence that management of HG in terms of discharge medications mainly followed local and national recommendations provides reassurance within the health professional community. Wider documentation of drugs prescribed to women with HG is required to enable full assessment of whether optimal drug management is being achieved.
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