Cytomegalovirus (CMV) infection and pregnancy-potential for improvements in Australasian maternity health providers' knowledge.

PURPOSE: To assess the knowledge, practice and attitudes of maternity clinicians regarding congenital cytomegalovirus (CMV). It is the most common congenital infection, and well-recognized cause of neurodevelopmental disability and hearing loss. New consensus recommendations state all pregnant women and health-care providers should be educated about congenital CMV infection and preventive measures. MATERIALS AND METHODS: An email questionnaire was distributed in October 2015 to specialists, diplomates (general practitioners), and trainees of the Royal Australian New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Victorian and New South Wales midwives. RESULTS: 774 responded: (37.3% specialists, 17.3% diplomates, 16.8% trainees, 28.6% midwives). Clinicians had variable knowledge of fetal sequelae, transmission routes and prevention. Overall, 30.2% felt confident about discussing CMV in pregnancy: less than 10% of midwives (7.4%) and less than half of specialists (47.1%, p < .0001). Only 8.8% of respondents routinely discussed CMV prevention with pregnant women. The majority (69.3%) responded that professional societies should make practice recommendations, and 88% thought more patient information was needed, preferably leaflets. CONCLUSIONS: Australasian maternity clinicians lack confidence and knowledge about congenital CMV. Few (<10%) routinely provide advice on prevention. There is urgent need for clinical guidance and patient information to reduce the burden of disease.

Inflammatory bowel disease in pregnancy: a population-based study of prevalence and pregnancy outcomes.

OBJECTIVE: To determine the prevalence of the inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn's disease (CD), in pregnant women and determine pregnancy and fetal/neonatal outcomes. DESIGN: Population-based cohort study. SETTING: New South Wales, Australia, 2001-11. POPULATION: A total of 630 742 women who delivered at ≥20 weeks of gestation. METHODS: Descriptive and multivariate regression analyses of perinatal data linked to hospital admission data. We compared birth outcomes of women with and without a documented diagnosis of IBD. MAIN OUTCOME MEASURES: Caesarean section, severe maternal morbidity, preterm birth <37 weeks of gestation, planned preterm birth, small-for-gestational-age (birthweight <10th centile), perinatal mortality (stillbirth/neonatal death ≤28 days). RESULTS: In all, 1960 women (0.31%) with IBD, who had 2781 births (1183 UC, 1287 CD and 311 IBD-indeterminate). Women with IBD were more likely than women without IBD to have a caesarean section [41.5 versus 28.2%, adjusted risk ratio (aRR) 1.38, 95% CI 1.31-1.45], severe maternal morbidity (2.6 versus 1.6%, aRR 1.54, 95% CI 1.17-2.03), preterm birth (9.7 versus 6.6%, aRR 1.47, 95% CI 1.30-1.66), planned preterm birth (5.3 versus 2.9%, aRR 1.74, 95% CI 1.47-2.07), and their infants to be small-for-gestational-age (9.7 versus 9.5%, aRR 1.19, 95% CI 1.04-1.36). There was no evidence of a difference in perinatal mortality. CONCLUSION: Pregnancy-associated IBD is more common than previously reported. Pregnancies complicated by IBD at or near the time of birth have significantly higher rates of adverse pregnancy outcomes than pregnancies of women without IBD. TWEETABLE ABSTRACT: Increased rates preterm birth and caesarean section in women with inflammatory bowel disease.

Twin pregnancies complicated by gestational diabetes mellitus: a single centre cohort study.

AIMS: In women with a twin pregnancy, to determine the incidence of, risk factors for and outcomes of women with gestational diabetes mellitus, and assess how these have changed with a change in gestational diabetes screening. METHODS: Retrospective cohort study of women with a twin pregnancy attending an Australian tertiary hospital, 2002-2013. Information on gestational diabetes status, gestational diabetes risk factors and pregnancy outcomes was ascertained. Pregnancy outcomes included hypertensive disorders, twin birthweight centile and a composite adverse pregnancy outcome. Analysis was stratified pre/post screening protocol change (epoch 1: 2002-2009, epoch 2: 2010-2013) and by gestational diabetes status. RESULTS: Gestational diabetes was diagnosed in 86/982 (8.8%) women, increasing from 4.4% to 14.7% between epochs (P = 0.0001). The proportion of women with hypertensive disorders increased (11.7% vs. 13.4%, P = 0.009), but the proportion of infant's birthweight > 90th centile decreased (11.0% vs. 7.6%, P = 0.02) between epochs. Overall, 33.6% of women had ≥ 1 risk factors for gestational diabetes. Three-quarters (73.7%) of women overall had an adverse pregnancy outcome, with a slightly higher proportion in women with gestational diabetes compared with those with no gestational diabetes (79.7% vs. 73.1%, P = 0.06). The rate of the adverse pregnancy outcome did not change by epoch, after adjusting for maternal and pregnancy risk factors (adjusted odds ratio = 0.96, 95% confidence interval 0.73-1.26). CONCLUSIONS: Almost 1 in 10 women with a twin pregnancy were diagnosed with gestational diabetes, with the incidence of gestational diabetes increasing threefold with a new screening protocol. The pregnancy outcomes of women with a twin pregnancy did not change with increased detection and treatment for gestational diabetes.

Occurrence and recurrence of diabetes in pregnancy.

AIMS: To determine occurrence and recurrence rates of gestational diabetes among women having at least two consecutive pregnancies. Risk factors for recurrence of gestational diabetes and rates of second/third pregnancy pre-existing diabetes mellitus were also assessed. METHODS: Population-based study using longitudinally linked hospital discharge and birth records (2001-2009) in NSW, Australia. Participants included women without a pre-existing diagnosis of Type 1 or Type 2 diabetes at time of first pregnancy and with at least a first and second birth. Factors associated with recurrence of gestational diabetes were examined using multivariate log-binomial models to adjust for correlation within mothers and estimate relative risks and 95% confidence intervals. RESULTS: First occurrence of gestational diabetes was 3.7% (5315/142 843) in the first pregnancy and 2.7% (3689/137 528) in the second pregnancy. The recurrence rate of gestational diabetes in a second consecutive pregnancy was 41.2%. Risk of pre-existing diabetes in a pregnancy subsequent to one with first occurrence of gestational diabetes was 2.2% and 2.0% in the second or third pregnancy, respectively. Among women with a diagnosis of gestational diabetes in the first pregnancy, independent predictors of gestational diabetes recurrence were maternal age ≥ 35 years, ethnicity (Middle East/North Africa and Asia), pregnancy hypertension, large for gestational age infant and preterm birth in the first pregnancy, longer inter-pregnancy birth interval and pregnancy hypertension and multiple pregnancy in the second pregnancy. CONCLUSIONS: Gestational diabetes in a previous pregnancy is a strong indicator of future risk and a useful clinical marker for identifying women at elevated risk in a subsequent pregnancy.

Maternal vitamin D status in pregnancy and adverse pregnancy outcomes in a group at high risk for pre-eclampsia.

OBJECTIVE: To determine in a group of pregnant women if vitamin D status, based on serum 25-hydroxyvitamin D (25OHD) concentration, was associated with a subsequent risk of pre-eclampsia or adverse pregnancy outcomes. DESIGN: Prospective cohort study. SETTING: Vancouver, British Columbia, Canada (49°N). POPULATION: Women attending a specialist antenatal clinic because of clinical or biochemical risk factors for pre-eclampsia (n = 221). METHODS: Serum 25OHD concentration measured between 10 and 20 weeks of gestation. MAIN OUTCOME MEASURES: Pre-eclampsia and composite adverse pregnancy outcomes. RESULTS: Of the women, 78% were vitamin D insufficient (25OHD <75 nmol/l) and 53% were vitamin D deficient (25OHD <50 nmol/l). There was no difference in the rates of pre-eclampsia, gestational hypertension, preterm birth or composite adverse pregnancy outcomes by 25OHD concentration. CONCLUSIONS: Vitamin D deficiency and insufficiency were common in a group of women at high risk of pre-eclampsia; however, it was not associated with subsequent risk of an adverse pregnancy outcome.

Antenatal intravenous immunoglobulin in chronic immune thrombocytopenic purpura: case report and literature review.

Immune thrombocytopenic purpura (ITP) may complicate pregnancy and, uncommonly, may cause severe neonatal thrombocytopenia. However, it is difficult to predict which neonates are at risk of severe thrombocytopenia. Direct fetal sampling is not commonly done, as it poses significant risks to the fetus. Furthermore, appropriate antenatal treatment of neonates is controversial. We describe the case of a 32-year-old woman with chronic severe ITP and a previous severely affected infant, pregnant with trichorionic triplets, who was successfully managed with the use of weekly intravenous immunoglobulin 1 g/kg without recourse to direct fetal sampling.

Outcomes of pregnancies in women with pre-gestational diabetes mellitus and gestational diabetes mellitus; a population-based study in New South Wales, Australia, 1998-2002.

AIM: To determine population-based rates and outcomes of pre-gestational diabetes mellitus (pre-GDM) and gestational diabetes mellitus (GDM) in pregnancy. METHODS: This was a cross-sectional study, using linked population databases, of all women, and their infants, discharged from hospital following birth in New South Wales (NSW) between 1 July 1998 and 31 December 2002. Women with, and infants exposed to pre-GDM or GDM were compared with those without diabetes mellitus for pregnancy characteristics and outcomes. RESULTS: Women with a singleton pregnancy (n = 370,703) and their infants were included: 1248 women (0.3%) had pre-GDM and 17,128 (4.5%) had GDM. Of those women with pre-GDM, 57% had Type 1 diabetes, 20% had Type 2 diabetes and for 23% the type of diabetes was unknown. Major maternal morbidity or mortality was more common in women with pre-GDM (7.9%) [odds ratio (OR) 3.2, 95% confidence interval (CI) 2.6, 3.9] and in women with GDM (3.1%) (OR 1.2, 95% CI 1.1, 1.4) when compared with women without diabetes (2.6%). Major infant morbidity or mortality occurred more frequently in infants exposed to pre-GDM compared with no diabetes (13.6% vs. 3.1%) (OR 5.0, 95% CI 4.2, 5.8) and in infants exposed to GDM compared with no diabetes (3.2% vs. 2.3%) (OR 1.4, 95% CI 1.3, 1.5). CONCLUSIONS: Pre-GDM and GDM continue to be associated with an increased risk of adverse maternal and neonatal outcomes; however, women with GDM have adverse outcomes less frequently. Rates of GDM and pre-GDM appear to be increasing over time. Clinicians should consider the potential for adverse outcomes, and arrange referral to appropriate services.