Metformin Exposure and Risk of Hypertensive Disorders of Pregnancy in Patients with Type 2 Diabetes.

OBJECTIVE: Metformin has been found to have a role in promoting vascular remodeling and angiogenesis which may reduce the risk of developing preeclampsia. Prior studies have shown a decrease in the incidence of hypertensive disorders of pregnancy in patients with type 2 and gestational diabetes taking metformin. We hypothesize metformin exposure decreases the risk of developing hypertension in patients with type 2 diabetes. STUDY DESIGN: Retrospective cohort study from 2009 to 2019 of singleton pregnancies was complicated by type 2 diabetes. We compared patients who received metformin throughout pregnancy to those with no metformin exposure. The primary outcome was a hypertension composite defined as gestational hypertension, preeclampsia with or without severe features, HELLP syndrome, or eclampsia. Individual hypertensive outcomes and neonatal outcomes were secondarily evaluated. Logistic regression was used to adjust for confounding variables. RESULTS: A total of 254 pregnancies were included. Women exposed to metformin were significantly less likely to develop hypertension composite compared with nonexposed women (22.7 vs. 33.1%, aOR 0.53, 95% CI 0.29-0.96). The incidence of preeclampsia with severe features was also significantly lower in those who received metformin compared with those who did not (12.1 vs. 20.7%, aOR 0.38, 95% CI 0.18-0.81). There were no differences in preterm birth prior to 34 or 37 weeks, fetal growth restriction, or birth weight between the study groups. A subgroup analysis of women without chronic hypertension also had a significantly lower risk of developing preeclampsia with severe features (7.6 vs. 17.8%, aOR 0.35, 95% CI 0.13-0.94). CONCLUSION: Metformin exposure was associated with a decreased risk of composite hypertensive disorders of pregnancy in patients with pregestational type 2 diabetes. These data suggest that there may be benefit to metformin administration beyond glycemic control in this patient population. KEY POINTS: · Metformin use showed a decreased risk of a hypertension composite.. · Results were consistent in patients without chronic hypertension.. · Metformin may show benefit beyond glycemic control in women with type 2 diabetes..

Deficiencies in reproductive health counseling in liver transplant recipients.

BACKGROUND: In liver transplant (LT) recipients of childbearing age, there is often rapid return of fertility post-transplant. Our aim was to determine whether healthcare providers are documenting reproductive health counseling in LT recipients. METHODS: We performed a review of 365 LT recipients (164 female, 201 male) of childbearing age transplanted between 1994 and 2015 at a single center. We evaluated documentation of reproductive health counseling, content of the counseling and its provider. RESULTS: Reproductive health counseling was documented in 7% of LT recipients (14% of females, 0.5% of males). The transplant team provided the counseling in 56%, obstetrics/gynecology in 35%, and primary care in 9%. Twenty-four post-LT pregnancies occurred; these were unplanned in 13%. Miscarriage/stillbirth occurred in 7/24 pregnancies (29%). Mycophenolic acid was used by 20% of female recipients at conception. Only age at transplant (P = 0.001) and post-LT pregnancy was associated with documentation of reproductive health counseling in female recipients (P = 0.0001). CONCLUSION: Despite rapid return of fertility in reproductive-aged LT recipients, documentation of reproductive health counseling in this population is rare in men and women. This increases the potential for adverse maternal and fetal outcomes in this high-risk population.

Perinatal Outcomes Associated With Institutional Changes Early in the COVID-19 Pandemic.

OBJECTIVE: Many institutions implemented policy changes to protect patients and clinicians during the COVID-19 pandemic. This study examines how institutional policy changes and patient behaviors affected perinatal outcomes. We hypothesized that obstetric practice changes occurred and that these changes affected perinatal outcomes. METHODS: We conducted a retrospective cohort study of singleton pregnancies delivered at a single institution with low incidence of COVID-19. Deliveries occurring from December 15, 2019 through March 14, 2020 were designated as the pre-COVID-19 group. Those occurring from March 15, 2020, through June 15, 2020, were designated the COVID-19 group. The primary outcome is a perinatal composite defined as delivery ≥ 41 weeks, hypertensive disorder of pregnancy at term, unplanned Cesarean delivery, term neonatal intensive care unit admission, 42-day maternal readmission, and 7-day neonatal readmission. Additional maternal, neonatal, and delivery composites also were analyzed, and we evaluated all individual outcomes secondarily. RESULTS: Of 2,268 deliveries, 1,210 occurred during the COVID-19 period. Four of the 1,210 (0.3%) were diagnosed with COVID-19. Women during the COVID-19 period were more likely to present in spontaneous labor and less likely to undergo induction. Maternal and neonatal length of stay was also shorter. There was no difference in the perinatal composite between the 2 groups (36.3% vs 36.7% [OR 1.05; 95% CI, 0.86-1.21]). There was a significant increase in deliveries occurring at or after 41 weeks (4.7% vs 6.9% [OR 1.83; 95% CI, 1.00-3.34]). There was no difference in maternal, neonatal, and delivery composites or the outcomes assessed individually. CONCLUSIONS: We demonstrated significant changes in clinical practice secondary to policy changes and patient behaviors during the COVID-19 pandemic. As an institution that globally adopted ARRIVE (A Randomized Trial of Induction Versus Expectant Management) practices, we noted fewer inductions, more women presenting in labor and more women delivering at or after 41 weeks. We also noted a shorter length of hospital stay for the mother-baby dyad. Overall, these changes in clinical practice did not affect perinatal outcomes.

A case of severe preeclampsia leading to the diagnosis of de novo abnormal fatty acid metabolism and ACE gene deletion.

BACKGROUND: Enzymes involved in the metabolism of free fatty acids are essential for the proper use of caloric intake. Abnormal enzymes unable to degrade fatty acids will result in an accumulation of fatty acids in organs like the liver, impairing its function. CASE: A 28-year-old primigravid woman underwent induction of labour because of severe preeclampsia. She was subsequently found to be a carrier for mutations in several fatty acid enzymes as well as the angiotensin converting enzyme. CONCLUSION: During pregnancy, the increased need for fatty acid degradation will expose women who are carriers of mutations in these enzymes. The clinical manifestations in such women include acute fatty liver of pregnancy that may mimic severe preeclampsia. Strict metabolic control to avoid excess fatty acid degradation may allow for better pregnancy outcomes and newborn assessment.

Outcomes for fetal echogenic bowel during the second trimester ultrasound.

OBJECTIVE: To investigate the association between fetal echogenic bowel (FEB) during the second trimester and perinatal outcome. METHODS: A retrospective chart review of FEB during the second trimester over 3 years. RESULTS: A total of 56 women were identified of 9067 screened (0.6%) women. Forty-seven agreed to genetic counseling (84%). Of those, 22 (39%) agreed to an amniocentesis. There were three cases of trisomy 21, one case of trisomy 18 and one case of fetal CMV infection. Twelve fetuses had an adverse outcome (21%), with only three of them having an echogenic bowel as the only finding. CONCLUSIONS: In our study, almost 80% of the fetuses had an uncomplicated perinatal outcome. FEB was present as the only finding in only 5% of the fetuses with an adverse outcome. A potential association with placental abnormalities and a low prevalence of viral infections was observed. These findings may be of use in counseling parents.