Impact of bariatric surgery on maternal gestational weight gain and pregnancy outcomes in women with obesity: A population-based cohort study from Qatar.

BACKGROUND: Bariatric surgery is performed in obese women of reproductive age to help achieve a healthy prepregnancy weight to reduce the complications associated with obesity in pregnancy. However, these procedures can impact maternal nutrition and gestational weight gain (GWG). This study evaluates the maternal and neonatal outcomes in women with prepregnancy bariatric surgery and determines the impact on GWG. METHODS: This study included 24 weeks gestation or more pregnancies, with a maternal BMI at delivery of 30 kg/m2 or more. It was categorized into two groups based on whether they had prepregnancy bariatric surgery (exposed) or not (unexposed). The outcomes included gestational diabetes (GDM), gestational hypertension (GHT), mode of delivery, preterm birth (PTB), GWG, birthweight (BW) and customized BW centiles, low birthweight (LBW), congenital anomalies, and admission to the neonatal intensive unit (NICU). Categorization was also done based on the adequacy of GWG (low, adequate, and excess). RESULTS: A total of 8,323 women were included in the study, 194 of whom had prepregnancy bariatric surgery. After adjusting for confounders, the exposed group had a mean GWG 1.33 kg higher than the unexposed group (95% CI 0.55-2.13, p = 0.001). The exposed group had higher odds of PTB (aOR 1.78, 95% CI 1.16-2.74, p = 0.008), CD (aOR 6.52, 95% CI 4.28-9.93, p < 0.001), LBW in term babies (aOR 2.60, 95% CI 1.34-5.03, p = 0.005), congenital anomalies (aOR 2.64, 95% CI 1.21-5.77, p = 0.015), low APGAR score (aOR 3.75, 95% CI 1.12-12.5, p = 0.032) and 80.4g lesser birthweight (95% CI -153.0, -5.8; p = 0.034). More women in the low GWG category had LBW babies (28.6% versus 6.7% in the high GWG group, p = 0.033), lowest mean BW and median BW centiles (2775 grams versus 3289 grams in the high GWG group, p = 0.004 and 57.5% versus 74.5% in the high GWG group, p = 0.040, respectively). CONCLUSION: The findings of this study highlight differences in perinatal outcomes such as preterm birth, low birth weight, congenital anomalies, cesarean deliveries, and gestational weight gain between post-bariatric women and controls. These insights can help inform the planning and provision of appropriate maternity care to enhance patient safety and outcomes. The results of this study can also guide the counseling of reproductive age-group women who are planning to undergo bariatric surgery.

Review of socioeconomic risk factors for cesarean births: a population-based study.

OBJECTIVES: The reasons for increased cesarean section (CS) rates are complex and multifactorial. The goal of this study was to look at different social and economic factors that might be causing more cases of CS in the population. STUDY DESIGN: A retrospective population-based cohort study. Data was taken from the Perinatal Neonatal Outcomes Research study in the Arabian Gulf (PEARL study) registry. Data from 60,728 live births ≥ 24 weeks of gestation were analyzed. In this study, various socioeconomic factors, such as maternal nationality, religion, educational level, employment status, parental income, consanguinity, housing, preterm birth, and tall stature, were examined for women undergoing cesarean section (CS) and their economic outcomes. Women who underwent vaginal delivery (VD) were compared. There are risks associated with pregnancy, smoking, assisted conception, and prenatal care. RESULTS: 60,728 births ≥ 24 weeks gestation were included in the analysis. 17,535 women delivered by CS (28.9%). Women with university-level -education and above were more likely to deliver by CS (61%), as compared to illiterate women or women with basic education at elementary or secondary levels (OR 0.73, CI 95%: P: <0.0001). Working women were more likely to deliver by CS (OR 1.40, CI 95%, P value <0.0001). Women living in rented houses were less likely to achieve a normal delivery (71.8%) (OR 1.40, CI 95%; P: <0.0001) as compared to women living in owned houses (74.7%). Women over 20 years old tended to achieve more VD compared to women less than 20 years old. P value <0.0001. Smoking was associated with lower chances of VD, with 42.4% of smokers delivered by CS compared to 28.3% of non-smokers (OR 1.87, CI 95%; P: <0.0001). Assisted conception was associated with higher CS rates as compared to spontaneous conceptions (OR 0.39; P: <0.0001). We found no statistically significant differences in how babies were born based on the mother's nationality, the father's job, or the mother's income. CONCLUSIONS: Higher education, employed mothers, smoking, and living in rented houses were socioeconomic factors associated with a higher rate of CS in our population. Furthermore, women who had regular antenatal care were more at risk for delivery by cesarean section, which could be related to other comorbidities increasing the likelihood of cesarean birth rather than antenatal care itself. In our population, assisted reproduction was associated with a higher probability of cesarean delivery.

Prophylactic Sildenafil in Preterm Infants at Risk of Bronchopulmonary Dysplasia: A Pilot Randomized, Double-Blinded, Placebo-Controlled Trial.

BACKGROUND: Bronchopulmonary dysplasia (BPD) is the need for oxygen therapy at 36 weeks postmenstrual age (PMA). Sildenafil has been shown to enhance the lung alveolarization and vascularization in newborn animal models after lung injury and has possible therapeutic potential for the prevention of BPD. OBJECTIVE: To perform a proof-of-concept, Phase II, pilot randomized, double-blind, clinical trial to study the efficacy of sildenafil in preventing BPD, in postnatal (< 24 h), extremely and very preterm infants. METHODS: This Phase II, pilot randomized, double-blind, clinical trial was conducted in the Neonatal Intensive Care Unit of Women's Wellness and Research Center, Doha, Qatar during 2012-2014. Infants of 240/7-296/7 weeks' gestation were eligible if they needed respiratory or oxygen support ≥ 25% at randomization, and if they were at a postnatal age of < 24 h at randomization. Forty preterm infants were randomly assigned to receive off-label oral sildenafil (0.5 mg/kg every 6 h) or a placebo solution, for one week. The primary endpoints were the incidence of BPD and death at 36 weeks PMA, and the side effects. Secondary outcomes included the incidence of BPD and the respiratory support at day 28 of life, duration of oxygen use, fraction of inspired oxygen use at 36 weeks and 28 days of life, duration of hospitalization, and the incidence of significant retinopathy of prematurity, severe intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, patent ductus arteriosus, and late sepsis. RESULTS: No significant differences were observed between the sildenafil and placebo study groups in mortality at 36 weeks PMA (10% vs 20%, p = 1), respiratory support at 36 weeks (30% vs 25%, p = 0.57), and side effects (0% vs 0%). For all other secondary outcomes, no significant differences were detected. CONCLUSIONS: While not associated with side effects, off-label oral sildenafil did not demonstrate benefits in the prevention of BPD or death in the extreme and very preterm infants. Future studies of dosing and efficacy that target different regimens of sildenafil are warranted before sildenafil is recommended for the prevention of BPD.

Newborn screening for remethylation disorders and vitamin B12 deficiency-evaluation of new strategies in cohorts from Qatar and Germany.

BACKGROUND: Newborn screening is a precondition for early diagnosis and successful treatment of remethylation disorders and classical homocystinuria (cystathionine-ß-synthase deficiency). Newborn screening for classical homocystinuria using total homocysteine measurement in dried blood spots has been very successfully performed for many years for newborns from Qatar. METHODS: A new optimized newborn screening strategy for remethylation disorders and homocystinuria was developed and evaluated for newborns from Qatar using total homocysteine measurement as first-tier and methionine, methionine-phenylalanine-ratio and propionylcarnitine as second-tiers. Proposed cut-offs were also retrospectively evaluated in newborn screening samples of 12 patients with remethylation disorders and vitamin B12 deficiency from Qatar and Germany. RESULTS: Over a 12 months period, the proposed strategy led to a decrease in the recall rate in homocysteine screening for Qatar from 1.09% to 0.68%, while allowing for additional systematic inclusion of remethylation disorders and vitamin B12 deficiency into the screening panel for Qatar. In the evaluated period the applied strategy would have detected all patients with classical homocystinuria identified by the previous strategy and in addition 5 children with maternal nutritional vitamin B12 deficiency and one patient with an isolated remethylation disorder. Additional retrospective evaluation of newborn screening samples of 12 patients from Germany and Qatar with remethlyation disorders or vitamin B12 deficiency showed that all of these patients would have been detected by the cut-offs used in the proposed new strategy. In addition, an adapted strategy for Germany using methionine, methionine-phenylalanine-ratio and propionylcarnitine as first-tier, and homocysteine as a second-tier test was also positively evaluated retrospectively. CONCLUSIONS: The proposed strategy for samples from Qatar allows inclusion of remethylation disorders and vitamin B12 deficiency in the screening panel, while lowering the recall rate. An adapted second-tier strategy is presented for screening in Germany and will be prospectively evaluated over the next years in a pilot project named "Newborn Screening 2020".

Newborn Screening for Vitamin B6 Non-responsive Classical Homocystinuria: Systematical Evaluation of a Two-Tier Strategy.

BACKGROUND: In classical homocystinuria (HCU, MIM# 236200) due to the deficiency of cystathionine ß-synthase (EC 4.2.1.22) there is a clear evidence for the success of early treatment. The aim of this study was to develop and evaluate a two-tier strategy for HCU newborn screening. METHODS: We reevaluated data from our newborn screening programme for Qatar in a total number of 125,047 neonates including 30 confirmed HCU patients. Our hitherto existing screening strategy includes homocysteine (Hcy) measurements in every child, resulting in a unique dataset for evaluation of two-tier strategies. Reevaluation included methionine (Met) levels, Met to phenylalanine (Phe) ratio, and Hcy. Four HCU cases identified after database closure were also included in the evaluation. In addition, dried blood spot samples selected by Met values >P97 in the newborn screening programs in Austria, Australia, the Netherlands, and Taiwan were analyzed for Hcy. RESULTS: Met to Phe ratio was found to be more effective for first sieve than Met, sorting out nearly 90% of normal samples. Only 10% of the samples would have to be processed by second-tier measurement of Hcy in dried blood spots. As no patient with HCU was found neither in the samples investigated for HCU, nor by clinical diagnosis in the other countries, the generalization of our two-tier strategy could only be tested indirectly. CONCLUSION: The finally derived two-tier algorithm using Met to Phe ratio as first- and Hcy as second-tier requires 10% first-tier positives to be transferred to Hcy measurement, resulting in 100% sensitivity and specificity in HCU newborn screening.

Outcomes of 28+1 to 32+0 weeks gestation babies in the state of Qatar: finding facility-based cost effective options for improving the survival of preterm neonates in low income countries.

In this retrospective study we did a comparative analysis of the outcome of 28(+1) to 32(+0) weeks gestation babies between the State of Qatar and some high income countries with an objective of providing an evidence base for improving the survival of preterm neonates in low income countries. Data covering a five year period (2002-2006) was ascertained on a pre-designed Performa. A comparative analysis with the most recent data from VON, NICHD, UK, France and Europe was undertaken. Qatar's 28(+1) to 32(+0) weeks Prematurity Rate (9.23 per 1,000 births) was less than the UK's (p < 0.0001). Of the 597 babies born at 28(+1) to 32(+0) weeks of gestation, 37.5% did not require any respiratory support, while 31.1% required only CPAP therapy. 80.12% of the MV and 96.28% of CPAP therapy was required for <96 hours. 86.1% of the mothers had received antenatal steroids. The 28(+1) to 32(+0) weeks mortality rate was 65.3/1,000 births with 30.77% deaths attributable to a range of lethal congenital and chromosomal anomalies. The survival rate increased with increasing gestational age (p < 0.001) and was comparable to some high income countries. The incidence of in hospital pre discharge morbidities in Qatar (CLD 2.68%, IVH Grade III 0.84%, IVH Grade IV 0.5%, Cystic PVL 0.5%) was less as compared to some high income countries except ROP >/= Stage 3 (5.69%), which was higher in Qatar. The incidence of symptomatic PDA, NEC and severe ROP decreased with increasing gestational age (p < 0.05). We conclude that the mortality and in hospital pre discharge morbidity outcome of 28(+1) to 32(+0) weeks babies in Qatar are comparable with some high income countries. In two thirds of this group of preterm babies, the immediate postnatal respiratory distress can be effectively managed by using two facility based cost effective interventions; antenatal steroids and postnatal CPAP. This finding is very supportive to the efforts of international perinatal health care planners in designing facility-based cost effective options for low income countries.

Newborn population screening for classic homocystinuria by determination of total homocysteine from Guthrie cards.

OBJECTIVE: To allow early recognition of cystathionine beta-synthase by newborn screening. STUDY DESIGN: Total homocysteine was determined in dried blood spots with a novel, robust high-performance liquid chromatography method with tandem mass spectrometry. Quantification of homocysteine was linear over a working range up to 50 micromol/L. For mutation analysis, DNA was tested for 2 mutations common in Qatar. RESULTS: Both methods proved to be suitable for high throughput processing. In 2 years, 7 infants with classic homocystinuria were identified of 12,603 native Qatari infants, yielding an incidence of 1:1800. Molecular screening would have missed 1 patient homozygous for a mutation not previously identified in the Qatari population. Over a period of 3 years, a total of 14 cases of classic homocystinuria were detected by screening of homocysteine from all newborn infants born in Qatar (n = 46 406). Homocysteine was always elevated, whereas methionine was elevated in only 7 cases. CONCLUSIONS: The study offers a reliable method for newborn screening for cystathionine beta-synthase deficiency, reaching a sensitivity of up to 100%, even if samples are taken within the first 3 days of life.

Molecular neonatal screening for homocystinuria in the Qatari population.

We report the results of molecular neonatal screening for homocystinuria (cystathionine beta-synthase deficiency) in neonates of Qatari origin, developed in conjunction with a novel biochemical screening approach. DNA was extracted from dried blood spots (DBS); the prevalent Qatari CBS gene mutation p.R336C (c.1006C>T) and a second mutation were tested with specific TaqMan assays. Over a period of 2 years we screened 12,603 neonates and identified six affected neonates homozygous for p.R336C. There were 225 heterozygous carriers for p.R336C. One additional child with homocystinuria detected through biochemical screening was homozygous for a mutation not previously identified in Qatar. Homocystinuria in the Qatari population has an incidence of 1:1,800, the highest in the world and even higher than previously estimated. Allele frequency of the mutation p.R336C is approximately 1%, displaying a significant deviation from Hardy Weinberg equilibrium. In conclusion, first-line molecular neonatal screening is technically feasible and may be developed as an option for presymptomatic identification of genetic disorders caused by specific mutations or a limited number of prevalent mutations. However, sensitivity for the diagnosis of disorders caused by various mutations is limited even in a homogeneous population such as Qatar.