Treatment options of Adolescent Gestational Diabetes: Effect on Outcome.

OBJECTIVES: Teenage pregnancy with gestational diabetes mellitus (GDM) offers a real challenge to the health system and needs a special care. We aimed to evaluate possible obstetrical and neonatal adverse events of different treatment protocols in adolescent GDM including lifestyle, metformin (MTF), and insulin. METHODS: All teen pregnant women ≤ 19 years old visiting Baghdad Teaching Hospital throughout four years (from June 1, 2016 till May 31, 2020) diagnosed with GDM were included in this cohort study and followed-up closely throughout pregnancy and after delivery. Included adolescents were put on lifestyle alone during the first week of presentation. Adolescents who reached target glucose measurements were categorized into lifestyle group, while other adolescents were randomly allocated into MTF and insulin groups. Also, adolescent pregnant women without GDM were recruited as control group using computer randomization. RESULTS: The GDM (110 cases) and control (121 individuals) groups had matched general features at recruitment except for diabetes family history. Also, GDM treatment groups had matched features. Glycemic readings (fasting and random) was significantly (p< 0.05) higher in insulin group having odds ratio (OR) of 1.41, and 1.57, respectively. In MTF group, significant protective OR was found in preeclampsia (OR=0.76, p< 0.05). MTF showed non-significant protective OR regarding prematurity and five minutes Apgar score>7 [(OR=0.83, p=0.24), and (OR=0.94, p=0.73), respectively], and significant protective association with large for gestational age and admission to neonatal intensive unit. Insulin had significantly higher prematurity, small for gestational age, and hypoglycemia [OR=1.89, 2.53, and 2.84, respectively]. CONCLUSION: Metformin (MTF) showed less pregnancy and neonatal complications in adolescent GDM than insulin and lifestyle.

Neonatal Seizures in Iraq: Cause and Outcome.

During a daily neonatology practice, seizures are a continuous challenge as a common neurological disease with a wide range of underlying etiologies, and considerable risks of morbidity and mortality. This study aimed to clarify the rate, etiological factors and outcomes of neonatal seizures, and a possible foresight of neonatal death in Iraq. A prospective cohort study was conducted in neonates with seizures admitted to 3 major neonatology centers in Baghdad, Iraq, from 1st of December 2017 till the end of May 2018. Both term and preterm neonates affected by seizures were recruited with a total number of 203 patients. Perinatal asphyxia (n = 81; 39.90%), infection (n = 77; 37.93%), and metabolic abnormalities (n = 52; 25.62%) were most common causes for seizures. Death occurred in 66 neonates (32.51%), with higher mortality rates found in preterm neonates. Six adverse prognostic indicators were shown to be significant: positive pressure resuscitation, mechanical ventilation, perinatal asphyxia, infection, gestational age (preterm babies), and low birth weight (< 2,500 g). Neonatal seizures may be the first manifestation of neurological insults, and they are most commonly caused by perinatal asphyxia, followed by infection, and metabolic disturbances. Prevention of neonatal seizures is much more important than the treatment of them for the reduction of neonatal mortality. The effective strategies should therefore be proper medical care and management for mothers and neonates before, during and after delivery to prevent neonatal infections, perinatal asphyxia, low birth weight, prematurity, metabolic abnormalities, and other risk factors of neonatal seizures.

Maternal and neonatal outcomes in adolescent pregnant women with one prior Cesarean section in Baghdad

Objective: Repeat adolescent pregnancy is a hot topic worldwide and imposes a challenge on the health system, especially when faced with limited resources. We aimed to assess maternal and neonatal outcomes in adolescent pregnant women with one prior cesarean section (CS). Material and Methods: Singleton adolescent pregnant women with one prior CS scar were recruited and divided into two groups based on the obstetric decision for delivery and/or mother's wish, either trial of labor (TL) or elective cesarean section (ECS). If TL failed, an emergency CS was performed. Results: Out of the total 109 involved women, TL and ECS groups included 78 (71.6%) and 31 (28.4%) women, respectively. Emergency CS was done for 57 (52.3%) women from the TL group, leaving only 21 (19.3%) women with successful TL who had statistically significant (non-recurrent) indications of the prior CS [12 (57.1%)]. Malpresentation (n=24; 77.4%) was the major indication in the ECS group, while fetal distress (n=29; 50.9%) was the main cause of failed TL. Total maternal morbidities in the TL group were significantly higher for adjusted [1.5 (1.1-4.2)] and non-adjusted odds ratios (OR) [2.4 (1.6-5.6)]. Neonatal complications, such as admission to neonatal intensive care unit, were higher in the TL group without reaching significance. However, the adjusted OR [1.9 (1.1-3.3)] for perinatal asphyxia was significantly increased in TL group. Conclusion: Maternal morbidities and perinatal asphyxia were significantly higher in the TL group of adolescent women compared with the ECS group in this study.

Obstetric and neonatal complications in large for gestational age pregnancy with late gestational diabetes

Objective: Gestational diabetes (GDM) is increasing in prevalence with effects starting in-utero, leading to excessive fetal growth. It is the leading cause of many perinatal complications. The aim was to determine the rate of obstetric and neonatal complications in pregnant women with high fetal weight and a recent diagnosis of GDM during the third trimester, despite normal earlier glycemic control. Material and Methods: Prospective cohort study over four years involving pregnant women regularly visiting a single center who had normal glycemic index at 24-28 gestational weeks and ultrasonography (US) suggested high fetal weight during the third trimester. Oral glucose tolerance test was given, dividing the sample into the late GDM (LGDM) and the non-LGDM group. Results: Of 176 women, 24 (13.64%) had LGDM, and 152 (86.36%) had non-LGDM. After exclusions these groups' sizes were (n=21) in LGDM and (n=132) in non-LGDM. Hemoglobin A1c level was significantly higher in LGDM than non-LGDM (5.9% versus 5.1%). However, obstetric and neonatal complications were largely comparable (p≥0.05) but higher in LGDM than non-LGDM women. Exceptions to this were birth weight (3219 g versus 3326 g), large for gestational age at delivery (85.72% versus 88.64%), and gestational age at delivery (37.9 versus 38.2 weeks) in the LGDM vs. non-LGDM groups, respectively. There was a significantly higher cesarean section (CS) rate (76.19% versus 51.52%; p<0.05) in the LGDM group. Conclusion: The rate of newly diagnosed LGDM in pregnant women with high fetal weight during the third trimester by US was 13.64%. They had comparable obstetric and neonatal complications with non-GDM women, except for the rate of CS that was significantly higher in LGDM women.

Fecal incontinence as the sole presentation of focal epilepsy; a case report.

Focal epilepsy is a surge in brain activity arising from a localised area of the cerebral cortex; it can be sub-classified in different categories including motor, sensory, autonomic and cognitive subtypes. A clinical case report of a 11-year-old girl was diagnosed with frequent fecal incontinence four or more times daily for more than two months. An electroencephalogram (EEG) study suggested a prominent interictal spike and sharp wave discharge on the left hemisphere, mainly at the frontotemporal region without loss of consciousness or even speech disruption. This could be due to the normal EEG study of the dominant hemisphere. A magnetic resonance imaging study was done to exclude space-occupying lesions or focal lesions of the left hemisphere of the brain. An impression was made with abnormal EEG showing focal epileptiform activity as a final diagnosis. The patient was treated with Leviteracetam anti-epileptic drug 250 mg twice daily with significant clinical improvement at a 3-month follow-up.

Differences in perinatal outcomes in teenage mothers with their first and third pregnancies and predictors of adverse neonatal events: A cross-sectional study.

BACKGROUND: Repeated teenage pregnancy is a major burden on the healthcare system worldwide. OBJECTIVE: We aimed to compare teenagers with their first and third pregnancies and to evaluate the likelihood of neonatal complications. MATERIALS AND METHODS: This cross-sectional study was performed on female teenagers (aged ≤ 19 yr) with singleton pregnancies. The subjects (n = 298) were screened over 12 months. Ninety-six women were excluded, based on the exclusion criteria. The remaining subjects (n = 202) were divided into two groups: teenagers with first pregnancy (n = 96) and teenagers with third pregnancy (n = 47). The subjects were observed throughout pregnancy and delivery. The final sample size of the first and third pregnancy groups was 96 and 47, respectively. RESULTS: There was a significant risk of preeclampsia in the first pregnancy group (p = 0.01). Low birth weight, five-min Apgar score < 7, and neonatal intensive care unit admission were the most significant neonatal outcomes in the first pregnancy group. In the third pregnancy group, significant predictors of neonatal complications included very young age in the first pregnancy ( ≤ 15 yr), an inter-pregnancy interval < 2 yr, current anemia, and history of obstetric and/or neonatal complications in previous pregnancies. CONCLUSION: Based on the results, teenagers with their first pregnancy had comparable obstetric outcomes (except for preeclampsia) as teenagers with their third pregnancy, whereas neonatal complications occurred more frequently in the first pregnancy group. Overall, we can predict high-risk neonates in the third pregnancy, based on the abovementioned parameters.

Effects of excessive tea consumption on pregnancy weight gain and neonatal birth weight.

OBJECTIVE: Tea lovers are increasing worldwide. We hope that this report is the first to discuss the possible impacts of high black tea consumption on gestational weight gain (GWG) and birth parameters. METHODS: Throughout one year, a total of 7,063 pregnant ladies coming for first antenatal visit were screened in a major tertiary center. Of them, 1,138 were involved and divided according to their preference into 3 groups: excessive tea (ET), usual tea (UT), and mixed beverages group. The study included women who gave birth to healthy neonates. RESULTS: The rate of ET consumption was 4.13% with a total of 41 cases. The UT group (controls) comprised 94 women. ET was significantly associated (P<0.05) with maternal age, parity, occupation, smoking, and poor GWG starting from 30 weeks' gestation until delivery, low birth weight, and small for gestational age (SGA). Poor GWG had a higher relative risk (with 95% confidence interval) in the ET group than in the UT group in crude (1.84 [0.85-2.43]) and risk adjusted models (1.25 [0.28-2.26]). Further, similar results were obtained for SGA in the crude and 3 adjusted models, where the first model was adjusted for bio-obstetrical variables, the second for social parameters, and the third for all factors included in the previous models (1.53 [0.62-2.81], 1.52 [0.71-2.50], and 1.46 [0.78-2.39]), respectively. CONCLUSION: Consumption of large amounts of daily black tea during pregnancy (≥1,500 mL) is a significant cause of poor GWG and SGA.

Green tea influence on iron overload in thalassemia intermedia patients: a randomized controlled trial.

Background: Although iron chelation therapies have been available for many years for thalassemia intermedia patients, iron accumulation remains the major cause of death. Therefore, the need for additional chelation options is in demand. This randomized controlled study aimed to understand the effects of green tea on iron balance in thalassemia intermedia patients. Methods: Using a random selection method, 141 thalassemia intermedia patients were initially screened for inclusion in this trial; only 68 patients included after applying exclusion criteria. Two equal groups were generated (n=34/group): green tea (three cups/day after meals) + usual treatment (deferasirox iron chelator and on demand blood transfusion); and control (only usual treatment). The study lasted for a period of 12 months. Patients failing to comply to the trial methodology were excluded, leaving a final total of 29 patients in the green tea group and 28 patients in the control group. Liver iron concentration, and serum ferritin were assessed at baseline and 12 months, while hemoglobin levels were assessed monthly. Results: At baseline, both groups were matched regarding general demographics. At 12 months, the net drop of liver iron concentration in the green tea group (7.3 mg Fe/g dry weight) was significantly higher than the control group (4.6 mg Fe/g dry weight) (p<0.05). This was also seen with serum ferritin; net reduction in green tea and control groups were 1289 ng/ml and 871 ng/ml, respectively (p<0.05). Hemoglobin levels were slightly higher in the green tea group compared with the control group, but this was not significant. Conclusions: Regular green tea consumption had a significant capability to improve iron deposition in thalassemia intermedia patients who already undergo deferesirox iron chelation therapy. Trial registration: UMIN-CTR Clinical Trials Registry, UMIN000040841 (retrospectively registered June 21, 2020).

Deferasirox in thalassemia: a comparative study between an innovator drug and its copy among a sample of Iraqi patients.

BACKGROUND: The health care industry is witnessing an increasing trend in the use of generic medicines because of their presumed low cost compared with innovator medicines. The aim of this study was to determine and compare the performance of the copy drug Osveral® and its innovator drug deferasirox (Exjade®). METHODS: A prospective observational study including 223 patients receiving the branded medicine Exjade® and 101 patients receiving the copy Osveral® was carried out. Data were assessed for a 1-year period and included clinical symptoms, serum ferritin (SF), serum creatinine (SC), and alanine aminotransferase (ALT). Data were analyzed with SPSS version 22 software (SPSS, Chicago, IL, USA). RESULTS: The median age of the sample was 8 years. There was no significant difference in gender distribution between the two groups (p = 0.625). Nausea was the most frequently reported adverse effect followed by diarrhea and abdominal pain in both groups. Patients receiving Exjade® had a higher relative reduction of SF at the end of the study compared with the Osveral® group (19.9% versus 9.93%, p = 0.028). SC was found to be significantly higher in the Osveral® group than in the Exjade® group throughout the study period. The mean platelet count was higher in the Exjade® group. ALT was significantly higher among patients receiving Osveral® over the last three months of the study. CONCLUSIONS: Exjade® showed a better ability to reduce SF, with less liver toxicity, and better hemostasis profile. No congenital anomalies associated with short-term use of both drugs during pregnancy were observed or reported.

Relationship between liver iron concentration determined by R2-MRI, serum ferritin, and liver enzymes in patients with thalassemia intermedia.

BACKGROUND: Iron overload is a risk factor affecting all patients with thalassemia intermedia (TI). We aimed to determine whether there is a relationship of serum ferritin (SF) and alanine aminotransferase (ALT) with liver iron concentration (LIC) determined by R2 magnetic resonance imaging (R2-MRI), to estimate the most relevant degree of iron overload and best time to chelate in patients with TI. METHODS: In this cross-sectional study, 119 patients with TI (mean age years) were randomly selected and compared with 120 patients who had a diagnosis of thalassemia major (TM). Correlations of LIC, as determined by R2-MRI, with SF and ALT levels, were assessed in all participants. A P-value <0.05 was considered statistically significant. RESULTS: SF and LIC levels were lower in patients with TI than in those with TM; only ferritin values were significant. We found a statistically significant relationship between SF and LIC, with cut-off estimates of SF in patients with TI who had splenectomy and those who entered puberty spontaneously (916 and 940 ng/mL, respectively) with LIC >5 mg Fe/g dry weight (P<0.0001). A significant relationship was also found for patients with TI who had elevated ALT level (63.5 U/L), of 3.15 times the upper normal laboratory limit, using a cut-off for LIC ≥5 mg Fe/g dry weight. CONCLUSION: We determined the cut-off values for ALT and SF indicating the best time to start iron chelation therapy in patients with TI, and found significant correlations among iron overload, SF, and ALT.