Reducing laboratory costs through rational testing in suspected pre-eclampsia.

The current electronic laboratory order set at Epsom and St Helier University Hospitals NHS Trust for suspected pre-eclampsia includes a full blood count, urea and electrolytes, liver function, gamma-glutamyltransferase and uric acid. Local and national guidelines do not recommend the use of gamma-glutamyltransferase or uric acid for the investigation or monitoring of pre-eclampsia, as they are poor predictors of maternal and neonatal outcomes. We aimed to remove the automatic inclusion of gamma-glutamyltransferase and uric acid from the electronic laboratory order set for suspected pre-eclampsia. Stakeholders were approached to gain an understanding of whether gamma-glutamyltransferase and uric acid were being used in the clinical assessment of suspected pre-eclampsia. Obstetric consultants and maternity staff confirmed that they do not use uric acid in their clinical assessment, despite the laboratory phoning with abnormal results. In addition, an isolated gamma-glutamyltransferase rise is of no particular significance and is not part of the National Institute for Health and Care Excellence (NICE) diagnostic criteria for pre-eclampsia. The baseline number of gamma-glutamyltransferase and uric acid requests from the maternity department was identified over 2 months. The hospital information technology service was then asked to remove gamma-glutamyltransferase and uric acid from the electronic laboratory order set. The number of gamma-glutamyltransferase and uric acid requests from the maternity department following the intervention was identified over 2 months. A significant reduction in both gamma-glutamyltransferase and uric acid requests were noted. In addition, the midwives within the maternity assessment unit noted a significant reduction in phone calls from the laboratory to escalate abnormal blood results. This has saved the trust money and reduced staff time answering phone calls regarding abnormal blood results. A repeat assessment at 8 months following the removal of gamma-glutamyltransferase and uric acid demonstrated sustainability of the project.

Birth weight in pregnancies complicated by maternal heart disease.

OBJECTIVE: To assess median and percentile birthweight distribution in women with various groups of heart disease relative to a contemporaneous comparison group. METHODS: Data on birth weight and gestational age were collected from 1321 pregnancies ≥24 weeks' gestation in 1053 women with heart disease from seven UK maternity units. Women were assigned to one of 16 groups according to their cardiac lesion. In units where it was possible, data on two births, one delivering before and one after index cases, were collected, giving 2307 comparators. Birthweight percentiles (corrected for gestational age, sex and parity) were calculated using Aberdeen norms. We assessed the association of birth weight with cardiac lesion, maternal hypoxaemia (saturations <90%), systemic ventricular function and beta-blockers. RESULTS: 1321 pregnancies in women with heart disease and 2307 comparators were studied. Almost all groups with heart disease had lower median and percentile birth weights than comparators, significantly in 10 groups, the biggest effect seen in women with Fontan circulation, pulmonary hypertension, prosthetic heart valves, systemic right ventricle, Marfan syndrome, repaired tetralogy of Fallot and cardiomyopathy (in that order). In 307 pregnancies, women took beta-blockers; median birth weight adjusted for maternal age, parity and the effect of the cardiac lesion was 3116.7 g (IQR 790.4) when beta-blockers were used and 3354.3 g (IQR 634.1) when they were not (p<0.001). 17 women had saturations <90%, and median birth weight was significantly lower, 3105.4 g (IQR 1288.9) versus 3387.7 g (IQR 729.8) (p=0.006). CONCLUSION: Our findings identify specific groups of women with heart disease at risk of having a small baby.

Retrospective UK multicentre study of the pregnancy outcomes of women with a Fontan repair.

BACKGROUND: The population of women of childbearing age palliated with a Fontan repair is increasing. The aim of this study was to describe the progress of pregnancy and its outcome in a cohort of patients with a Fontan circulation in the UK. METHODS: A retrospective study of women with a Fontan circulation delivering between January 2005 and November 2016 in 10 specialist adult congenital heart disease centres in the UK. RESULTS: 50 women had 124 pregnancies, resulting in 68 (54.8%) miscarriages, 2 terminations of pregnancy, 1 intrauterine death (at 30 weeks), 53 (42.7%) live births and 4 neonatal deaths. Cardiac complications in pregnancies with a live birth included heart failure (n=7, 13.5%), arrhythmia (n=6, 11.3%) and pulmonary embolism (n=1, 1.9%). Very low baseline maternal oxygen saturations at first obstetric review were associated with miscarriage. All eight women with saturations of less than 85% miscarried, compared with 60 of 116 (51.7%) who had baseline saturations of ≥85% (p=0.008). Obstetric and neonatal complications were common: preterm delivery (n=39, 72.2%), small for gestational age (<10th percentile, n=30, 55.6%; <5th centile, n=19, 35.2%) and postpartum haemorrhage (n=23, 42.6%). There were no maternal deaths in the study period. CONCLUSION: Women with a Fontan circulation have a high rate of miscarriage and, even if pregnancy progresses to a viable gestational age, a high rate of obstetric and neonatal complications.

Renal tubular acidosis type 4 in pregnancy.

We describe the clinical course of renal tubular acidosis (RTA) type 4 in pregnancy, which has not been previously published. Renal tubular acidosis type 4 is a condition associated with increased urinary ammonia secondary to hypoaldosteronism or pseudohypoaldosteronism. Pregnancy may worsen the hyperkalaemia and acidosis of renal tubular acidosis type 4, possibly through an antialdosterone effect. We advise regular monitoring of potassium and pH throughout pregnancy to ensure safe levels are maintained.