Conservative Management of Presumed Fetal Anemia Secondary to Maternal Chemotherapy for Acute Myeloid Leukemia.

Acute myeloid leukemia occurs rarely during pregnancy. When it is diagnosed remote from term, treatment in the form of daunorubicin plus cytarabine induction with consolidative cytarabine is typically undertaken after the first trimester. There is little data to guide fetal monitoring, in particular, whether and how often middle cerebral artery peak systolic velocity (MCA PSV) should be measured to screen for fetal anemia. Cytarabine may be particularly myelosuppressive to the fetus, but information pertaining to the management of this complication is also lacking in published literature. To our knowledge, we present the first case of presumed severe fetal anemia related to in utero exposure to chemotherapy that was managed conservatively with close sonographic monitoring, including serial measurement of MCA PSV. This case suggests that in the absence of hydrops fetalis or other signs of fetal decompensation, expectant management with ultrasound twice weekly, including MCA PSV, is appropriate. Ultrasounds may be decreased to weekly when MCA PSV does not suggest fetal anemia. Screening for fetal anemia can provide helpful information to guide the timing of chemotherapy administration and delivery. Key Points Chemotherapy for acute myeloid leukemia can cause fetal anemia.Fetal MCA PSV can be used to safely and effectively screen for fetal anemia.Observation of fetal anemia due to chemotherapy is reasonable, in the absence of hydrops.Monitoring of fetal MCA PSV can help guide timing of chemotherapy and delivery.

Standardized Postpartum Follow-Up for Women with Pregnancy Complications: Barriers to Access and Perceptions of Maternal Cardiovascular Risk.

OBJECTIVE: Certain obstetrical complications are known to increase a woman's risk of future cardiovascular disease (CVD). The Maternal Health Clinic (MHC) provides postpartum cardiovascular risk counselling and follow-up; however, half of women referred do not attend. This study aimed to identify barriers to access, as well as whether attendance at the MHC improved the accuracy of patients' CVD risk perception. METHODS: MHC patients completed a CVD risk perception questionnaire prior to being assessed and 3 months after their appointment ("attendees"). Calculated lifetime CVD risk scores were compared with perceived risk to assess accuracy of risk perception. Patients who did not attend their MHC appointment ("non-attendees") were administered the questionnaire by phone and asked about perceived barriers to access. RESULTS: Sixty-seven of 137 eligible attendees (48.9%) completed both the pre- and post-MHC questionnaires. Significantly more participants accurately estimated their absolute CVD risk after their MHC appointment, although the majority continued to underestimate their risk. Among non-attendees, 81 of 130 women (62.3%) completed the questionnaire. The most common barriers to access cited were being too busy with childcare, accessing follow-up with the patient's family doctor instead, and difficulty attending their appointment. CONCLUSION: Lack of time and inconvenience were two common barriers to accessing the MHC. Improved collaboration with primary care providers and use of telemedicine may help to mitigate these issues. Both attendees and non-attendees appeared to have an inadequate perception of CVD risk. Standardized postpartum CVD risk screening and counselling may be an effective method of providing these women with risk education and improving the accuracy of their risk perception.

We Should Proceed With Caution When It Comes to Antenatal Corticosteroids After 34 Weeks.

The Society for Maternal-Fetal Medicine recently released a statement supporting the use of antenatal corticosteroids for women at high risk of late preterm birth. This followed a trend of increasing use of antenatal corticosteroids after 34 weeks' gestation, based on evidence for decreased respiratory morbidity. The absolute benefits, however, are relatively small. We should balance this against the possible long-term harms of corticosteroids after 34 weeks before expanding the indications for their antenatal use.

Evaluating the Postpartum Maternal Health Clinic: How Patient Characteristics Predict Follow-Up.

OBJECTIVE: At Kingston General Hospital, women who have pregnancy-related cardiovascular risk indicators (e.g., preeclampsia, gestational hypertension, gestational diabetes) are offered standardized six-month postpartum follow-up for cardiovascular disease risk screening and counselling. We sought to assess how patient characteristics predict attendance at follow-up. METHODS: We undertook a chart review of 650 patients who delivered between April 2011 and December 2014 and had preeclampsia, gestational hypertension, or gestational diabetes. Logistic regression was used to analyze the relationship between clinical and demographic variables and attendance at the follow-up clinic. RESULTS: Increasing age (in years) was significantly correlated with attendance at follow-up (adjusted OR [aOR] 1.08, 95% CI 1.04 to 1.12). Women who had preeclampsia were significantly more likely to attend than women who had gestational hypertension or gestational diabetes (aOR 1.54, 95% CI 1.05 to 2.26). Women who were known to be non-smokers or whose smoking status was not recorded were significantly more likely to attend follow-up (aOR 2.47, 95% CI 1.32 to 4.62). There was a trend towards lower follow-up for women from census tracts or subdivisions with a greater proportion of individuals without educational certificate, diploma, or degree, but this was not statistically significant (aOR 0.10, 95% CI 0.01 to 1.22). CONCLUSION: There is significant selection bias among women who attend follow-up for postpartum cardiovascular disease risk screening and counselling after pregnancies complicated by preeclampsia, gestational hypertension, or gestational diabetes.