SOMANZ position paper on the management of nausea and vomiting in pregnancy and hyperemesis gravidarum.

This is a brief summary of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) evidence-based guideline for the management of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum (HG). The full guideline and executive summary including auditable outcomes are freely available on the SOMANZ website [https://www.somanz.org/guidelines.asp]. The guideline includes a proposed SOMANZ definition of NVP and HG and evidence-based practical advice regarding the investigation and management of NVP, HG and associated conditions including thyroid dysfunction. A practical algorithm for assessment and management as well as an individual patient management plan and self-assessment tools are included.

SOMANZ guidelines for the investigation and management sepsis in pregnancy.

SOMANZ (Society of Obstetric Medicine Australia and New Zealand) has written a guideline to provide evidence-based guidance for the investigation and care of women with sepsis in pregnancy or the postpartum period. The guideline is evidence-based and incorporates recent changes in the definition of sepsis. The etiology, investigation and treatment of bacterial, viral and non-infective causes of sepsis are discussed. Obstetric considerations relevant to anaesthetic and intensive care treatment in sepsis are also addressed. A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women have contributed to the development of the guidelines. This is an executive summary of the guidelines.

Haemorrhagic complications of peripartum anticoagulation: A retrospective chart review.

BACKGROUND: Women with venous thromboembolism (VTE), thrombophilias or mechanical heart valves may require anticoagulation during pregnancy and postpartum. The incidence of postpartum hemorrhage (PPH) in the literature is 2.9-6%, but the rate while on anticoagulation is not well documented. AIMS: To determine the incidence of haemorrhagic complications associated with the use of peripartum anticoagulation, and the types and risk factors for haemorrhagic complications. METHODS: A retrospective chart review was conducted on women who delivered at an academic teaching hospital and received peripartum anticoagulation between January 2000 and August 2009. Women with known bleeding disorders were excluded. RESULTS: In total, 195 cases were identified with mean age 31.3 years and gestational age of 37.7 weeks. Of these, 49% had a history of VTE, 21% had active VTE in the index pregnancy, and 63% had vaginal delivery. Types of anticoagulation used antepartum were unfractionated heparin (UFH) (43%) and low molecular weight heparin (LMWH) (36%), with 26% receiving therapeutic doses. The rate of haemorrhagic complications was 12.8%, with majority being PPH (80%). Sixty percent of the PPH occurred before reintroduction of anticoagulation postpartum. Use of therapeutic UFH antepartum was associated with increased risk of haemorrhagic complications compared to LMWH (OR 3.08, 95% CI 0.663 - 15.03, p = 0.183). CONCLUSION: The rate of haemorrhagic complications is higher in women on peripartum anticoagulation compared with published incidence in unselected obstetric populations; however, this rate is similar to our institution's reported rates. Our findings inform clinicians about competing risks of thrombotic and haemorrhagic complications in this population.

Glucose control during labour in diabetic women.

OBJECTIVES: Glucose control during labour is important for mother and neonate, with high rates of neonatal hypoglycemia reported in offspring of women with pre-existing or gestational diabetes (48% and 19%, respectively). How glucose control can be achieved is rarely specified. We conducted a chart review of a standardized approach using an iterative intravenous insulin-glucose infusion. METHODS: We performed a retrospective review of the records of 274 diabetic women during labour. Fifty-five women had type 1 diabetes, 55 had type 2 diabetes, and 164 had gestational diabetes (GDM). The protocol used hourly capillary blood glucose determinations, each prompting changes in insulin-glucose infusion rates as required. Outcomes included maternal blood glucose levels three hours before delivery and neonatal hypoglycemia (blood glucose < 2 mmol/L). RESULTS: The insulin-glucose infusion was used in 47% of women with type 1, type 2, and gestational diabetes requiring ≥ 0.5 units/kg/day of insulin during pregnancy and in 8% of women with GDM treated by diet or < 0.5 units/kg/day of insulin. The overall rate of maternal hypoglycemia was low (6.6% with blood glucose ≤ 3.5 mmol/L and 1.5% ≤ 3.0 mmol/L) pre-delivery; 13.9% of women had a blood glucose level ≥ 7.0 mmol/L. The neonatal hypoglycemia rate was 7.3% (4.9% in the offspring of women with GDM and 10.9% in the offspring of women with pre-existing diabetes). In women with type 1 and type 2 diabetes and high-dose insulin-requiring GDM, the rate of blood glucose values outside the range of 3.6 to 6.9 mmol/L was lower in those using the intravenous protocol (16.7%) than in those not using it (34.8%), but this reduction was not statistically significant. CONCLUSION: Standardized management for diabetic women in labour using an intravenous insulin-glucose protocol was effective in achieving stable maternal blood glucose levels with low rates of neonatal hypoglycemia.

A successful term pregnancy using in-center intensive quotidian hemodialysis.

A 30-year-old woman with stage V chronic kidney disease presented at 7 weeks gestation. She had no uremic symptoms; however, blood urea nitrogen (BUN) was 33.6 mg/dL. Because of the well-established negative relationship between BUN and fetal outcomes, dialysis was initiated with a nocturnal home hemodialysis (NHD)-like prescription performed in-center for logistical reasons. She received 36 hours per week of dialysis. Following the initiation of renal replacement therapy, the predialysis BUN was within the normal physiologic range. The patient had an uncomplicated pregnancy with delivery of a healthy 3000 g infant at 39 weeks gestation. This case adds to the growing literature that supports more intensive dialysis in the pregnant women than was previously recommended. This dose of dialysis should be offered to women in an in-center setting if nocturnal home hemodialysis is not available or feasible.

A practical approach to using spot urine protein/creatinine ratios for assessing proteinuria in pregnancy.

OBJECTIVE: The aim of this study is to assess the diagnostic accuracy of the spot urine protein/creatinine ratio compared with the 24-hour urine protein in pregnancy. STUDY DESIGN: In this prospective cohort study of inpatient pregnant women, the protein/creatinine ratio and dipstick protein were assessed from a single urine sample collected at the start of the 24-hour urine. Both tests were compared with the 24-hour urine protein for correlation and test characteristics. RESULTS: In the 196 specimens analysed, we found a strong correlation between the spot urine protein/creatinine ratio and 24-hour urine protein (r (2) = 0.78, P < 0.01). A protein/creatinine ratio <0.1 ruled out significant proteinuria (≥300 mg/day) with sensitivity and negative predictive value 100%. A protein/creatinine ratio ≥0.4 detected significant proteinuria (specificity and positive predictive value of 100%). A protein/creatinine ratio ≥4.6 had a specificity and positive predictive value of 100% for detecting severe proteinuria (≥5000 mg/day). Urine dipsticks correlated poorly with the 24-hour urine protein (r (2) = 0.40, P = 0.826). Nineteen percent of dipsticks reading nil or trace were false-negative results. CONCLUSION: The spot urine protein/creatinine ratio correlated well with the 24-hour urine protein and performed better than the urine dipsticks. Significant proteinuria in pregnancy was excluded if the protein/creatinine ratio was <0.1 and identified when it was ≥0.4.