Association between betamethasone levels and respiratory distress syndrome in preterm births: A prospective cohort study.

The recommended fixed dosage of betamethasone for pregnancies at risk of preterm birth was determined in the 1970s, regardless of gestational age (GA), number of fetuses, and maternal weight. We aimed to examine the association between maternal and neonatal betamethasone serum levels and neonatal respiratory distress syndrome (RDS) and to examine whether levels correlate with maternal weight, GA, or number of fetuses. A prospective study was conducted at a single academic medical center between August 2016 and February 2019. Women received betamethasone and delivered between 28+0 and 34+6 weeks were included. Maternal serum levels (MSLs), and neonatal serum levels (NSLs) of betamethasone at delivery were analyzed using Corticosteroid enzyme-linked immunosorbent assay kit. RDS was diagnosed according to clinical and radiographic findings. We assumed that the sensitivity of NSLs to detect RDS is 95%; hence, 150 neonates were needed (power 80%, alpha 0.05). Overall, 124 women were included; including 96 (77.4%) singletons, 26 (21.0%) twins, and 2 (1.6%) triplets, corresponding to 154 neonates. RDS was diagnosed in 35 neonates (22.7%). After adjusting for GA, time elapsed from the last dose, and number of doses, NSLs were associated with RDS (relative risk: 0.97, 95% confidence interval: 0.94-0.99, p = 0.011). A level of 6.00 ng/ml predicted RDS with a sensitivity of 80.0% and specificity of 64.7%. Adjusted MSLs were not associated with RDS. Both maternal and neonatal serum levels were not associated with the number of fetuses and maternal weight. In conclusion, NSLs are associated with RDS whereas MSLs are not.

Relationship between patient ethnicity and prevalence of anemia during pregnancy and the puerperium period and compliance with healthcare recommendations - implications for targeted health policy.

BACKGROUND: Anemia is common during pregnancy and the puerperium. The association of ethnicity as well as other characteristics with anemia and compliance with healthcare recommendations has not been studied sufficiently and needs to be explored in order to implement a targeted health policy. We examined the association between ethnicity and the risk for prenatal and puerperium anemia and the compliance with healthcare recommendations. This effort aims to guide reforms in policies and practices that will assist in decreasing anemia prevalence in Israel. METHODS: This study was a secondary analysis of a prospective cohort study database including 1558 women who delivered vaginally at Emek Medical Center. Anemia was assessed before delivery by obtaining a complete blood count (CBC). After delivery, CBCs were taken in cases of postpartum hemorrhage, symptoms consistent with anemia, prenatal anemia or other clinical indications. The study population was divided according to their ethnicity (Jews and Arabs). The primary outcomes were anemia before delivery, anemia in the immediate postpartum and 6 weeks postpartum, and compliance with healthcare recommendations, which was defined as the rate of women who performed a routine CBC test 6-weeks-postpartum. RESULTS: The rates of anemia before delivery and in the puerperium period were similar between Jews and Arabs (before delivery: 88 (11%) versus 98 (14%); 6 weeks postpartum: 55 (21%) vs 68 (28%), respectively;p > 0.05). Iron supplementation was high in both groups during pregnancy (~ 90%) and lower during the postpartum for Jews compared to Arabs (72% vs 83%,respectively; P < .0001). Only one third of the patients performed a CBC 6-weeks-postpartum regardless of ethnicity. CONCLUSION: Overall compliance with health recommendation was high during pregnancy but low postpartum and was reflected in anemia persistence regardless of ethnicity. Because of the adverse long term impact of anemia on patient's health, new policies need to be developed to improve patient's compliance postpartum. A possible strategy is to combine the follow-up of the mother with the one of the newborn in the family health stations (Tipat Halav) and the community clinics similarly to the close follow-up during pregnancy. Additional methods may include active summoning for CBC test and assuring iron supplement consumption.

Hemoglobin drop following postpartum hemorrhage.

Postpartum hemorrhage (PPH) is defined as blood loss of ≥ 500-1000 ml within 24 h after delivery. Yet, assessment of blood loss is imprecise. The present study aimed to profile the hemoglobin (Hb) drop after vaginal delivery with versus without PPH. This was a secondary analysis of a prospective cohort study of women who delivered vaginally. Women were included if complete blood counts (CBC) before and after delivery were taken until stabilization (N = 419). Women were categorized into the PPH group and controls, for whom post-delivery CBCs were performed due to indications unrelated to bleeding. The PPH patients were then classified as either overt or occult PPH (symptoms related to hypovolemia without overt bleeding) subgroups. The primary endpoint was mean Hb drop after delivery. One hundred and ten (26%) and 158 (38%) women presented with overt PPH or occult PPH, respectively; 151 (36%) women were included in the control group. Mean Hb decrease from baseline was 3.0 ± 1.6, 2.0 ± 1.4 and 0.9 ± 1.0 g/dl, respectively (p < 0.0001). In all groups, maximal rate of Hb decline was in the first 6-12 h postpartum and plateaued after 24-48 h. At 48 h post-delivery, 95% and 86% of women who had dropped to Hb ≤ 9.5 and < 7 g/dl, respectively, reached those thresholds. Taken together, an Hb decrease ≥ 2 g/dl was consistent with PPH diagnosis and should be followed for at least 48 h after delivery.

Evaluation of postpartum anaemia screening to improve anaemia diagnosis and patient care: A prospective non-randomized before-and-after anaemia screening protocol implementation study.

We assessed the efficacy of a screening protocol for postpartum anaemia diagnosis and treatment in the maternity ward. A prospective non-randomized before-and-after anaemia screening protocol implementation study during two consecutive periods was conducted. Women who were scheduled for vaginal birth were tested for haemoglobin (Hb) before delivery. During the first period (June 29-October 10, 2015; N = 803) Hb was measured postpartum for women with anaemia-related symptoms, postpartum haemorrhage, or pre-delivery severe anaemia (Hb < 8 g/dL; "symptoms" group). During the second period (October 11, 2015-January 27, 2016; N = 755) Hb was also measured in all women with pre-delivery anaemia [i.e., Hb < 10.5 g/dL] ("screening" group). The primary outcomes were the rates of women with (1) postpartum anaemia diagnosis (Hb < 10 g/dL) and (2) administration of parenteral iron sucrose (indicated for postpartum Hb ≤ 9.5 g/dL). The detection rate of postpartum anaemia was higher in the screening group compared with the symptoms group (140 (19%) versus 100 (12%), ORadjusted 2.2 95%CI [1.6-3.0], respectively). The iron sucrose treatment rate was also higher (110 (15%) versus 88 (11%), ORadjusted 2.0 95%CI [1.4-2.7], respectively). A total of 122 women were diagnosed with moderate-severe anaemia in the screening group, 27 of whom (22%) were diagnosed solely due to the screening protocol. The results demonstrated that a routine screening of women with predelivery anaemia for postpartum anaemia led to increased anaemia diagnosis and consequently better medical care.

Effect of intermittent versus continuous bladder catheterization on duration of the second stage of labor among nulliparous women with an epidural: a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Catheterization type among women laboring with epidural analgesia who develop bladder retention has been reported to affect labor duration and mode of delivery. We aimed to compare the effect of continuous bladder catheterization (CC) with that of intermittent bladder catheterization (IC) on the duration of the second stage of labor. METHODS: In a randomized trial, term nulliparous women with singleton gestation who requested epidural analgesia and were unable to void spontaneously were eligible and randomized to either CC or IC. Epidural analgesia was maintained with patient control until delivery. The primary outcome was duration of the second stage of labor. Secondary outcomes were mode of delivery, and incidences of postpartum hemorrhage, bladder retention, and infection. It was assumed that, compared with IC, CC might better prevent bladder distention, which is thought to delay fetal descent. A sample size of 90 women in each group was calculated to be adequate to detect a reduction of 30 min in the duration of the second stage of labor among the CC group. RESULTS: Between July 2014 and May 2015, a total of 184 women were randomized and included in the analysis; 90 and 94 women in the CC and IC groups respectively. Demographic and obstetric characteristics were similar. Duration of the second stage was 121.0 ± 89.4 and 131.9 ± 87.5 min in the CC and IC groups respectively (p = 0.29). The two groups did not differ significantly with regard to delivery mode, third-stage duration, and incidences of postpartum hemorrhage, bladder retention, and urinary tract infection. CONCLUSION: Duration of the second stage of labor is not influenced by bladder catheterization type in nulliparous women receiving an epidural.

Glyburide Versus Metformin and Their Combination for the Treatment of Gestational Diabetes Mellitus: A Randomized Controlled Study.

OBJECTIVE: To compare the efficacy and safety of glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: In this prospective randomized controlled study, we randomly assigned patients with GDM at 13-33 weeks gestation and whose blood glucose was poorly controlled by diet to receive either glyburide or metformin. If optimal glycemic control was not achieved, the other drug was added. If adverse effects occurred, the drug was replaced. If both failed, insulin was given. The primary outcomes were the rate of treatment failure and glycemic control after the first-line medication according to mean daily glucose charts. RESULTS: Glyburide was started in 53 patients and metformin in 51. In the glyburide group, the drug failed in 18 (34%) patients due to adverse effects (hypoglycemia) in 6 (11%) and lack of glycemic control in 12 (23%). In the metformin group, the drug failed in 15 (29%) patients, due to adverse effects (gastrointestinal) in 1 (2%) and lack of glycemic control in 14 (28%). Treatment success after second-line therapy was higher in the metformin group than in the glyburide group (13 of 15 [87%] vs. 9 of 18 [50%], respectively; P = 0.03). In the glyburide group, nine (17%) patients were eventually treated with insulin compared with two (4%) in the metformin group (P = 0.03). The combination of the drugs reduced the need for insulin from 33 (32%) to 11 (11%) patients (P = 0.0002). Mean daily blood glucose and other obstetrical and neonatal outcomes were comparable between groups, including macrosomia, neonatal hypoglycemia, and electrolyte imbalance. CONCLUSIONS: Glyburide and metformin are comparable oral treatments for GDM regarding glucose control and adverse effects. Their combination demonstrates a high efficacy rate with a significantly reduced need for insulin, with a possible advantage for metformin over glyburide as first-line therapy.

Mode of delivery among women admitted with polyhydramnios.

A retrospective matched case control study was conducted to examine the incidence of caesarean delivery (CD) among women admitted with polyhydramnios with and without a trial of labour compared to women with normal amniotic fluid index (AFI). Singleton pregnancies diagnosed with polyhydramnios upon admission to labour between 2003 and 2013 were included. A control group (normal AFI) matched at a ratio of 1:1 was randomly selected. Primary outcome was the incidence of CD. A total of 588 women were included. The overall incidence of CD was significantly higher among women with polyhydramnios (31.3%) compared to the controls (18.7%), (p < .001). The incidences of both non-labouring caesarean and intrapartum operative deliveries were significantly higher among women with polyhydramnios compared to the controls (p = .007 and p = .01, respectively). On a multiple logistic regression model, polyhydramnios was found to be an independent risk factor for delivery by a caesarean (p = .0015; OR 2.0; 95%CI 1.30-2.90).

Measurement of betamethasone concentration in maternal serum treated for fetal lung maturity; Is it feasible?

BACKGROUND: The association between maternal serum concentration of betamethasone given for fetal lung maturity and perinatal outcome has not been investigated. This may be due to an absence of a reliable method for measuring serum betamethasone concentrations. We aimed in the current study to assess the feasibility of a specific ELISA kit to measure the concentrations of betamethasone in maternal serum and to examine the trend of sequential measurements after a course of betamethasone for fetal lung maturity. METHODS: Pregnant women at risk for preterm birth who received betamethasone between 24 and 34 weeks of gestation were prospectively included. Serum concentrations were determined before administering betamethasone (baseline), and 36 hours, 48 hours, 72 hours, and 5 to 7 days after the 1(st) dose. Betamethasone concentration in samples was determined using Corticosteroid ELISA kit. The Friedman test was used to test whether there were significant differences between the measurements. RESULTS: Five singleton pregnancies were included. Using the ELISA kit, betamethasone concentration in maternal serum samples was obtained for all women. Among the five measurements performed, the concentration was highest at 36 hours after the 1(st) dose and close to baseline at the 5(th) measurement performed after 5 to 7 days (p < 0.05). Serum concentration varied at each time point between the five women but similar trend was observed. CONCLUSION: Betamethasone concentration is measurable in the serum of pregnant women with this ELISA kit.

Relation of C-reactive protein and new-onset atrial fibrillation in patients with acute myocardial infarction.

Recent studies have implicated systemic inflammation in the genesis and maintenance of atrial fibrillation (AF). A robust inflammatory response is an integral component of the response to tissue injury during acute myocardial infarction (AMI). However, there is no information concerning the association between inflammation and AF in patients with AMI. We studied 1,209 patients admitted for AMI. C-reactive protein (CRP) was measured by a high-sensitivity assay within 12 to 24 hours after symptom onset. The relation between CRP and new-onset AF occurring during the hospital course and at 1 year was analyzed using multivariable logistic regression and Cox models, respectively. New-onset AF during hospitalization occurred in 6.5%, 10.4%, and 17.1% of patients in the first, second and third CRP tertiles, respectively (p trend <0.0001). In a multivariable logistic regression, adjusting for clinical variables and ejection fraction, compared with patients in the first CRP tertile, the odds ratios for AF were 1.5 (95% confidence interval 0.9 to 2.5, p = 0.15) and 2.0 (95% confidence interval 1.2 to 3.3, p = 0.008) in patients in the second and third CRP tertiles, respectively (p for trend = 0.007). In a Cox multivariate analysis, CRP remained an independent predictor of new-onset AF at 1 year. In conclusion, in a large cohort of patients with AMI, there was a graded positive association between increased CRP and new-onset AF. Inflammation may contribute to the development of AF in the setting of AMI.

Changes in haemoglobin levels during hospital course and long-term outcome after acute myocardial infarction.

AIMS: To study the prevalence and long-term prognostic significance of changes in haemoglobin levels during hospital course in survivors of acute myocardial infarction (AMI). METHODS AND RESULTS: A prospective study involving 1390 patients who were admitted with AMI. Median follow-up was 24 months. Multivariable Cox models were used to evaluate the relationship between nadir and discharge haemoglobin and mortality after hospital discharge. Anaemia was present in 248 patients on admission (17.8%) and in 502 patients at discharge (36.1%). Nadir haemoglobin during hospital course was 1.3 g/dL lower (IQR 0.6-2.2) when compared with baseline haemoglobin (P < 0.0001). Low nadir haemoglobin and discharge haemoglobin were strongly associated with increased mortality. After adjusting for clinical variables and ejection fraction, the hazard ratios for a 1 g/dL decrease in nadir haemoglobin and discharge haemoglobin were 1.36 (95% CI 1.19-1.55; P < 0.0001) and 1.27 (95% CI 1.16-1.40; P < 0.0001), respectively. CONCLUSION: The development of anaemia during hospitalization for AMI is frequent and is associated with an increased long-term mortality.

Fasting glucose in acute myocardial infarction: incremental value for long-term mortality and relationship with left ventricular systolic function.

OBJECTIVE: Elevation of blood glucose is a common metabolic disorder among patients with acute myocardial infarction (AMI) and is associated with adverse prognosis. However, few data are available concerning the long-term prognostic value of elevated fasting glucose during the acute phase of infarction. RESEARCH DESIGN AND METHODS: We prospectively studied the relationship between fasting glucose and long-term mortality in patients with AMI. Fasting glucose was determined after an >/=8 h fast within 24 h of admission. The median duration of follow-up was 24 months (range 6-48). All multivariable Cox models were adjusted for the Global Registry of Acute Coronary Events (GRACE) risk score. RESULTS: In nondiabetic patients (n = 1,101), compared with patients with normal fasting glucose (<100 mg/dl), the adjusted hazard ratio for mortality progressively increased with higher tertiles of elevated fasting glucose (first tertile 1.5 [95% CI 0.8-2.9], P = 0.19; second tertile 3.2 [1.9-5.5], P < 0.0001; third tertile 5.7 [3.5-9.3], P < 0.0001). The c statistic of the model containing the GRACE risk score increased when fasting glucose data were added (0.8 +/- 0.02-0.85 +/- 0.02, P = 0.004). Fasting glucose remained an independent predictor of mortality after further adjustment for ejection fraction. Elevated fasting glucose did not predict mortality in patients with diabetes (n = 462). CONCLUSIONS: Fasting glucose is a simple robust tool for predicting long-term mortality in nondiabetic patients with AMI. Fasting glucose provides incremental prognostic information when added to the GRACE risk score and left ventricular ejection fraction. Fasting glucose is not a useful prognostic marker in patients with diabetes.

Fasting glucose is an important independent risk factor for 30-day mortality in patients with acute myocardial infarction: a prospective study.

BACKGROUND: Stress hyperglycemia in patients with acute myocardial infarction has been associated with increased mortality. Most studies looked at the relationship between admission glucose (AG) and outcome; limited information is available about the clinical significance of fasting glucose (FG). METHODS AND RESULTS: We prospectively studied the relationship between FG and 30-day mortality in 735 nondiabetic patients with acute myocardial infarction. FG (> or =8-hour fast within 24 hours of admission) and AG were measured in each patient. At 30 days, 9 deaths (2%) occurred in patients with normal FG, and 11 (10%), 14 (13%), and 31 (29%) deaths occurred in the first, second, and third tertiles of elevated FG, respectively. Compared with normal FG (<110 mg/dL), the adjusted OR for 30-day mortality progressively increased with higher tertiles of elevated FG (first tertile, 4.6; 95% CI, 1.7 to 12.7; P=0.003; second tertile, 6.4; 95% CI, 2.5 to 16.6; P<0.0001; third tertile, 11.5; 95% CI, 4.7 to 20.0; P<0.0001). Compared with patients categorized as having normal AG (<140 mg/d), the adjusted ORs for tertiles of elevated AG were as follows: first tertile, 1.4 (95% CI, 0.5 to 3.8; P=0.54); second tertile, 3.0 (95% CI, 1.3 to 7.0; P=0.01); and third tertile, 4.4 (95% CI, 2.0 to 9.7; P<0.0001). Compared with patients with normal FG and AG, the adjusted ORs for 30-day mortality were 0.71 (95% CI, 0.15 to 3.4; P=0.67) in patients with elevated AG and normal FG, 3.4 (95% CI, 1.1 to 10.4; P=0.03) for patients with normal AG glucose and elevated FG, and 9.6 (95% CI, 3.5 to 26.0; P<0.0001) for patients with both elevated FG and AG. Comparing nested models showed that including AG failed to improve the prediction of the model based on FG (chi2=5.4, 3 df, P=0.15). In contrast, the addition of FG classes to the model based on AG improved model prediction (chi2=22.4, 3 df, P<0.0001). CONCLUSIONS: There is a graded relation between elevated FG and AG and 30-day mortality in patients with acute myocardial infarction. FG is superior to AG in the assessment of short-term risk.