Signs or symptoms of suspected preeclampsia - A retrospective national database study of prevalence, costs, and outcomes.

BACKGROUND: Most patients with signs or symptoms (s/s) of suspected preeclampsia are not diagnosed with preeclampsia. We sought to determine and compare the prevalence of s/s, pregnancy outcomes, and costs between patients with and without diagnosed preeclampsia. METHODS: This retrospective cohort study analyzed a large insurance research database. Pregnancies with s/s of preeclampsia versus a confirmed preeclampsia diagnosis were identified using International Classification of Diseases codes. S/s include hypertension, proteinuria, headache, visual symptoms, edema, abdominal pain, and nausea/vomiting. Pregnancies were classed as 1) s/s of preeclampsia without a confirmed preeclampsia diagnosis (suspicion only), 2) s/s with a confirmed diagnosis (preeclampsia with suspicion), 3) diagnosed preeclampsia without s/s recorded (preeclampsia only), and 4) no s/s, nor preeclampsia diagnosis (control). RESULTS: Of 1,324,424 pregnancies, 29.2 % had ≥1 documented s/s of suspected preeclampsia, and 14.2 % received a preeclampsia diagnosis. Hypertension and headache were the most common s/s, leading 20.2 % and 9.2 % pregnancies developed to preeclampsia diagnosis, respectively. Preeclampsia, with or without suspicion, had the highest rates of hypertension-related severe maternal morbidity (HR [95 % CI]: 3.0 [2.7, 3.2] and 3.6 [3.3, 4.0], respectively) versus controls. A similar trend was seen in neonatal outcomes such as preterm delivery and low birth weight. Cases in which preeclampsia was suspected but not confirmed had the highest average total maternal care costs ($6096 [95 % CI: 602, 6170] over control). CONCLUSION: There is a high prevalence but poor selectivity of traditional s/s of preeclampsia, highlighting a clinical need for improved screening method and cost-effectiveness disease management.

Factors associated with obtaining results on repeat cell-free DNA testing in samples redrawn due to insufficient fetal fraction.

Objectives: To investigate factors associated with obtaining results on repeat cell-free DNA testing for fetal trisomy after an initial sample with insufficient fetal fraction.Methods: A series of clinical laboratory samples was queried to identify patients with multiple samples drawn for the Harmony® prenatal test. Maternal demographics, gestational age, timing of sampling, and repeat test outcome were reviewed. Multivariate logistic regression analysis was used to determine the odds ratio of obtaining a result.Results: Two thousand nine hundred six unique pregnancies were identified with a sample submitted for repeat testing after an initial test with an insufficient fetal fraction. Overall, 53% obtained a result on the second draw. The odds of obtaining a result were associated with interval time between draws (per day, OR 1.040, 95% CI 1.031-1.051) and maternal weight (per kg, OR 0.988, 95% CI 0.985-0.991) but not maternal age, gestational age at initial draw, IVF status, or twin versus singleton pregnancy.Conclusions: The probability of obtaining a result with repeat cell-free DNA testing decreases with higher maternal weight and increases with the interval between draws. Waiting longer before collecting a repeat sample increases the probability of obtaining a result but should be considered in the context of the gestational age of the pregnancy and the clinical indication for testing.

Pregnancy and Birth Outcomes among Women with Idiopathic Thrombocytopenic Purpura.

OBJECTIVE: To examine pregnancy and birth outcomes among women with idiopathic thrombocytopenic purpura (ITP) or chronic ITP (cITP) diagnosed before or during pregnancy. METHODS: A linkage of mothers and babies within a large U.S. health insurance database that combines enrollment data, pharmacy claims, and medical claims was carried out to identify pregnancies in women with ITP or cITP. Outcomes included preterm birth, elective and spontaneous loss, and major congenital anomalies. RESULTS: Results suggest that women diagnosed with ITP or cITP prior to their estimated date of conception may be at higher risk for stillbirth, fetal loss, and premature delivery. Among 446 pregnancies in women with ITP, 346 resulted in live births. Women with cITP experienced more adverse outcomes than those with a pregnancy-related diagnosis of ITP. Although 7.8% of all live births had major congenital anomalies, the majority were isolated heart defects. Among deliveries in women with cITP, 15.2% of live births were preterm. CONCLUSIONS: The results of this study provide further evidence that cause and duration of maternal ITP are important determinants of the outcomes of pregnancy.

First Trimester Hemoglobin A1c Prediction of Gestational Diabetes.

Objective The objective of this study is to examine whether a first trimester hemoglobin A1c (A1C) of 5.7 to 6.4% predicts an abnormal second trimester oral glucose tolerance test (OGTT). Methods We conducted a retrospective cohort study of all women screened with A1C through 13 (6/7) weeks' gestation between January 1, 2011, and December 31, 2012. Prediabetic women (A1C of 5.7-6.4%) were compared with women with a normal first trimester A1C (< 5.7%). The primary outcome was an abnormal 2-hour, 75-g OGTT as defined by the International Association of Diabetes and Pregnancy Study Groups. Results There were 2,812 women who met inclusion criteria of whom 6.7% (n = 189) were prediabetic. Women with prediabetes were more likely to have gestational diabetes mellitus (GDM) even after adjusting for potential confounders (29.1 vs. 13.7%; adjusted relative risk, 1.48; 95% confidence interval, 1.15-1.89). There were no statistically significant differences in secondary outcomes except that women with prediabetes had less excessive gestational weight gain. A prediabetic-range A1C in the first trimester was associated with a 13% sensitivity and a 94% specificity for predicting GDM Conclusion Although women with prediabetes by first trimester A1C are significantly more likely to have GDM, the low sensitivity of an A1C in this range renders it a poor test to identify women who will develop GDM.

Racial/Ethnic Differences in Gestational Diabetes Prevalence and Contribution of Common Risk Factors.

BACKGROUND: The White House, the American Heart Association, the Agency for Healthcare Research and Quality, and the National Heart, Lung and Blood Institute have all recently acknowledged the need to disaggregate Asian American subgroups to better understand this heterogeneous racial group. This study aims to assess racial/ethnic differences in relative contribution of risk factors of gestational diabetes mellitus (GDM) among Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese), Hispanics, non-Hispanic blacks, and non-Hispanic whites. METHODS: Pregnant women in 2007-2012 were identified through California state birth certificate records and linked to the electronic health records in a large mixed-payer ambulatory care organisation in Northern California (n = 24 195). Relative risk and population attributable fraction (PAF) for specific racial/ethnic groups were calculated to assess the contributions of advanced maternal age, overweight/obesity (Centers for Disease Control and Prevention (CDC) standards and World Health Organization (WHO)/American Diabetes Association (ADA) body mass index cut-offs for Asians), family history of type 2 diabetes, and foreign-born status. RESULTS: GDM was most prevalent among Asian Indians (19.3%). Relative risks were similar across all race/ethnic groups. Advanced maternal age had higher PAFs in non-Hispanic whites (22.5%) and Hispanics (22.7%). Meanwhile family history (Asian Indians 22.6%, Chinese 22.9%) and foreign-borne status (Chinese 40.2%, Filipinos 30.2%) had higher PAFs in Asian subgroups. Overweight/obesity was the most important GDM risk factor for non-Hispanic whites, Hispanics, Asian Indians, and Filipinos when the WHO/ADA cut-off points were applied. Advanced maternal age was the only risk factor studied that was modified by race/ethnicity, with non-Hispanic white and Hispanic women being more adversely affected than other racial/ethnic groups. CONCLUSIONS: Overweight/obesity, advanced maternal age, family history of type 2 diabetes, and foreign-borne status are important risk factors for GDM. The relative contributions of these risk factors differ by race/ethnicity, mainly due to differences in population prevalence of these risk factors.

Impact of maternal nutrition and metabolism on health of the offspring.

Since the original publication of the theory of the fetal origins of adult diseases more than 15 years ago, extensive epidemiological studies have linked the environment in utero to adult health. Maternal nutrition and metabolism are major mechanisms by which the intrauterine environment programs the health of the offspring. Both growth-restricted and overgrown fetuses are at risk for postnatal disease. This paper summarizes the nutritional and metabolic causes of both these conditions and also reviews the interventions that have been tested to mitigate these effects.

Increased incidence of cardiac anomalies in pregnancies complicated by gastroschisis.

OBJECTIVE: The purpose of this study was to determine the incidence of congenital heart defects (CHD) in infants with gastroschisis. STUDY DESIGN: Infants with gastroschisis repair were identified from California hospital discharge data during the years 1992 to 1997. The frequency of concomitant diagnosis of CHD and other demographic, neonatal, and pregnancy outcomes were examined. RESULTS: Sixty-nine of the 621 infants had a diagnosis of CHD, with 16 having more than 1 lesion. Excluding cases possibly attributable to persistent fetal circulation, 25 infants with CHD remained, for an incidence rate of 4%. There was a significant (P = .014) increase in incidence of CHD in cases of gastroschisis complicated by bowel atresia. African American infants with gastroschisis had an increased risk of CHD (P = .009) compared with infants of other ethnicities. CONCLUSION: Contrary to conventional teaching that gastroschisis is an isolated anomaly, we found an increased incidence of concomitant CHD. Our data would suggest that detailed antepartum and/or postnatal cardiac evaluations are indicated in fetuses identified with gastroschisis.