Maternal and neonatal glycaemic control after antenatal corticosteroid administration in women with diabetes in pregnancy: A retrospective cohort study.

OBJECTIVE: To describe maternal and neonatal glycaemic control following antenatal corticosteroid administration to women with diabetes in pregnancy. DESIGN: Retrospective cohort study. SETTING: A tertiary hospital in Auckland, New Zealand. POPULATION: Women with diabetes in pregnancy who received antenatal corticosteroids from 2006-2016. METHODS: Corticosteroid administration, maternal and neonatal glycaemia data were retrieved from electronic patient records. Demographic data were downloaded from the hospital database. Relationships between variables were analysed using multivariate analysis. MAIN OUTCOME MEASURES: Maternal hyperglycaemia and neonatal hypoglycaemia. RESULTS: Corticosteroids were administered to 647 of 7317 of women with diabetes (8.8%) who gave birth to 715 babies. After an initial course of corticosteroids, 92% and 52% of women had blood glucose concentrations > 7 and > 10 mmol/L respectively. Median peak blood glucose concentration of approximately 10 mmol/L occurred 9 hours after corticosteroid administration and hyperglycaemia lasted approximately 72 hours. Thirty percent of women gave birth within 72 hours of the last dose of corticosteroids. Babies of women who were hyperglycaemic within 24 hours of birth were more likely to develop hypoglycaemia (< 2.6 mmol/L, OR 1.51 [95% CI 1.10-2.07], p = 0.01) and severe hypoglycaemia (≤ 2.0 mmol/L, OR 2.00 [95% CI 1.41-2.85], p < 0.0001) than babies of non-hyperglycaemic mothers. There was no association between maternal glycaemia within 7 days of the last dose of corticosteroids and neonatal hypoglycaemia. CONCLUSIONS: Hyperglycaemia is common in women with diabetes in pregnancy following antenatal corticosteroid administration. Maternal hyperglycaemia in the 24 hours prior to birth is associated with increased risk of neonatal hypoglycaemia. Limitations included the retrospective study design, so that not all data were available for all women and babies and the glucose testing schedule was variable.

Patterns of antenatal corticosteroid administration in a cohort of women with diabetes in pregnancy.

Antenatal corticosteroids administered to the mother prior to birth decrease the risk of mortality and major morbidity in infants born at less than 35 weeks' gestation. However, the evidence relating to women with diabetes in pregnancy is limited. Clinical guidelines for antenatal corticosteroid administration recommend that women with diabetes in pregnancy are treated in the same way as women without diabetes, but there are no recent descriptions of whether contemporary practice complies with this guidance. This study is a retrospective review of antenatal corticosteroid administration at a New Zealand tertiary hospital in women with diabetes in pregnancy. We found that in this cohort, for both an initial course at less than 35 weeks' gestation and repeat courses at less than 33 weeks', the administration of antenatal corticosteroid to women with diabetes in pregnancy is largely consistent with current Australian and New Zealand recommendations. However, almost 25% of women received their last dose of antenatal corticosteroid at or beyond the latest recommended gestation of 35 weeks' gestation. Pre-existing diabetes and planned caesarean section were independently associated with an increased rate of antenatal corticosteroid administration. We conclude that diabetes in pregnancy does not appear to be a deterrent to antenatal corticosteroid administration. The high rates of administration at gestations beyond recommendations, despite the lack of evidence of benefit in this group of women, highlights the need for further research into the risks and benefits of antenatal corticosteroid administration to women with diabetes in pregnancy, particularly in the late preterm and early term periods.

Reported adherence to current antenatal corticosteroid guidelines in Australia and New Zealand.

BACKGROUND: Antenatal corticosteroids (ANC) reduce mortality and morbidity in preterm babies, but prescription practices vary. AIMS: To assess obstetricians' compliance with the recommendations of the Australian and New Zealand clinical practice guidelines on use of ANC. MATERIALS AND METHODS: An anonymous online questionnaire was distributed to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RESULTS: All respondents reported prescribing an initial course of ANC according to the guidelines if preterm birth at 28 weeks' gestation was expected within 24 or 72 h. However, 22% reported prescribing ANC even if birth was not expected within seven days. This was reported more often by practitioners not using adjunct tests to predict preterm birth (14% vs 69%; P < 0.001). An initial course of ANC at ≥35 weeks was prescribed by 52% of respondents. However, 93% reported prescribing ANC at ≥35 weeks prior to elective caesarean section. Repeat courses of ANC were prescribed by 76% of respondents. Of these, 89% reported prescribing repeat courses beyond the guideline recommendations at ≥33 weeks and 29% exceeded the recommendations on number of repeat courses. CONCLUSIONS: For infants born at <35 weeks, current ANC prescribing patterns in Australia and New Zealand are consistent with the guideline recommendations and result in high rates of administration in this group. However, administration of ANC to groups where benefits have not been demonstrated is commonly reported. Adherence to the guideline recommendations would decrease ANC exposure to babies for whom there is no strong evidence of benefit.

An audit of first trimester ultrasound screening for chromosomal abnormalities.

BACKGROUND: Screening for Down syndrome has been funded in New Zealand since 2010 following the report 'Antenatal Down Syndrome Screening in NZ 2007' which identified that the practice of screening using maternal age and/or nuchal translucency (NT) without biochemical markers was unsafe and should not continue. AIM: This study aimed to assess the quality of the ultrasound component of first trimester screening in a metropolitan population. METHODS: Over a 5-month period, all available NT scan images for women referred to the Central Region Fetal Medicine Unit for an increased risk at first trimester screening or a fetal abnormality detected at the 20-week ultrasound scan were reviewed according to the Fetal Medicine Foundation (FMF) criteria and utilising the Herman Score. This is the standard which the National Screening Unit (NSU) and Ministry of Health (MOH) have mandated for the ultrasound component of the screening test. RESULTS: Of the 52 images, 4 (7.7%) studies were considered unacceptable and another 5 (9.6%) were considered intermediate. The mean score was 5.87 of a possible score of 9. Comparisons with Herman's data are presented and discussed. CONCLUSIONS: This review suggests that there is potential for the quality of the ultrasound component of the first trimester screening component to improve. This would in turn improve the performance of the screening program. We conclude that formal quality control of this screening program is urgently required.

Rate of postdates induction using first-trimester ultrasound to determine estimated due date: Wellington Regional Hospital audit.

AIM: The aim of this audit was to examine the effect of using first-trimester (<14 weeks) ultrasound scan to determine EDD (US EDD) on the rate of induction for postdates pregnancies at Wellington Regional Hospital. METHODS: Women with singleton live pregnancies who had postdates (≥41 weeks) induction at Wellington Hospital during January 2009 to November 2009 were identified using a computerised database [Perinatal Information Management System (PIMS)]. The first-trimester ultrasound images and reports for these women were retrieved and reviewed by a specialist in obstetric ultrasound. Only ultrasound studies that had technically satisfactory images at <14 weeks were included. RESULTS: A total of 329 women with a singleton live pregnancy were induced for postdates during the study period. Of these women, 50 (15.2%) were not ≥41 weeks on PIMS EDD and therefore on the best available evidence should not have been induced for being postdates. Of the remaining 279 women, 158 had first-trimester scans available for review. Forty-three of 158 (27%) were <41 weeks when US EDD was used. CONCLUSIONS: The rate of postdates inductions at Wellington NRH could be decreased by 38% if induction was limited to women over 41-week gestation and by using US EDD as opposed to last menstrual period EDD. The use of early gestational scans (<14 weeks) to estimate EDD lowers the rate of postdates induction. This is very similar to the observed findings in literature.

Herceptin (trastuzumab) therapy in a twin pregnancy with associated oligohydramnios.

Herceptin (trastuzumab) is an adjuvant chemotherapy agent used in treatment of certain breast cancers. Limited information is available on the use of herceptin in pregnancy. This case is a twin pregnancy exposed to herceptin until 23 weeks' gestation. One twin had chronic renal failure develop, whereas the other twin did not.

Sleep duration and quality in healthy nulliparous and multiparous women across pregnancy and post-partum.

BACKGROUND: Longitudinal studies of sleep during normal pregnancy and post-partum are rare, and interpretation of the findings is often hampered by methodological issues. Consequentially, there is still limited information on what constitutes normal sleep quality and quantity across pregnancy and early post-partum, for both nulliparous and multiparous women. AIMS: To quantify the change and variability in sleep duration and quality across pregnancy and post-partum for healthy nulliparous and multiparous women. METHODS: Nineteen women (eight nulliparous and 11 multiparous) wore an actigraph and completed a sleep diary to objectively measure sleep for seven nights during the second trimester, one week prior to delivery, and at one and six weeks post-partum. Mixed model analysis of variance and logistic regression were used to investigate changes in sleep across this timeframe. RESULTS: The largest changes in sleep occurred in the first week post-partum (1.5 h less sleep than during pregnancy, three times more sleep episodes in 24 h, 70% of women regularly napping during the day, and greatest day-to-day variability in sleep). Compared to multiparas, nulliparas generally had less efficient sleep, spent more time in bed and had greater wake after sleep onset in the second trimester, and spent less time in bed and had fewer sleep episodes a day at one week post-partum. CONCLUSIONS: These changes should be used to inform women about the extent of change in sleep, particularly early post-partum, and to help health-care providers identify women experiencing severe sleep loss and disruption and discuss possible coping strategies with them.

Reliability of ultrasound estimation of fetal weight in term singleton pregnancies.

AIM: To assess the reliability of ultrasound estimation of fetal weight undertaken antenatally at Wellington Hospital (Wellington City, New Zealand) in women with a singleton pregnancy = or >37 weeks gestation. METHOD: Data were collected retrospectively for pregnant women who had undergone ultrasound estimation of fetal weight <7 days prior to a term delivery (= or >37 weeks gestation) over the period of July 1998-June 2005. Stillbirths and multiple pregnancies were excluded. Ultrasound fetal weight estimations, calculated using a locally modified Woo formula, were compared with the infant's actual birth weight. RESULTS: A total of 1177 infants were studied. The mean absolute error and mean signed error (+/-SD) of ultrasound fetal weight estimations were 7.0+/-5.7% and -0.2+/-9.0%, respectively (n=1177). Three-quarters of estimations were within 10% of birth weight. Ultrasonic estimation of fetal weight tended to overestimate the weight of small infants (<2500 g; mean signed error = +3.5%+/-9.1%, n=98) and underestimate the weight of large infants (= or >4000 g; mean signed error = -3.3+/-8.7%, n=170). Both large and normal weight infants of women with diabetes tended to have their weight underestimated (mean signed error = -5.1+/-9.2%, n=48). Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasonic detection of fetal weight = or >4000 g in non-diabetic women were 61%, 96%, 69%, and 94%, respectively. For detection of fetal weight = or >4500, the figures were 50%, 98%, 47%, and 98%, respectively. CONCLUSION: The accuracy of ultrasound estimations of fetal weight performed at Wellington Hospital within 7 days of delivery in term singleton pregnancies was at least similar and sometimes better than that reported in other studies. For one in four women, however, the fetal weight estimation was more than 10% different from the actual birth weight of their infant. Ultrasound measurements had a tendency to overestimate the weight of small infants while underestimating the weight of both large infants and the infants of diabetic mothers. As the reliability of ultrasound estimation of fetal weight to detect larger babies was poor, the use of such an objective measurement in the management of suspected macrosomia in term singleton pregnancies should be avoided.

Red blood cell iso-immunisation in the Wellington area of New Zealand: the case for antenatal prophylaxis.

The present study aimed to calculate the rate of Rhesus D iso-immunisation during pregnancy in Wellington, New Zealand and to identify the timing of iso-immunisation. The notes of all women and their babies with positive antenatal anti-D antibody screens during the period 1994-2002 at the regional reference laboratory (Wellington Blood Transfusion Service) were reviewed to identify the antibody titre and the stage of pregnancy that the antibodies developed. Twelve percent of all tested pregnant women were Rhesus D negative and the annual immunisation rate during pregnancy was 1.4%. Sensitisation during the third trimester occurred in 50% of these women. Sensitisation in the third trimester was more common in primigravid women (87%) than in multiparous women (27%).