Pregnancies in women with Turner syndrome: a retrospective multicentre UK study.

OBJECTIVE: To determine the characteristics and outcomes of pregnancy in women with Turner syndrome. DESIGN: Retrospective 20-year cohort study (2000-20). SETTING: Sixteen tertiary referral maternity units in the UK. POPULATION OR SAMPLE: A total of 81 women with Turner syndrome who became pregnant. METHODS: Retrospective chart analysis. MAIN OUTCOME MEASURES: Mode of conception, pregnancy outcomes. RESULTS: We obtained data on 127 pregnancies in 81 women with a Turner phenotype. All non-spontaneous pregnancies (54/127; 42.5%) were by egg donation. Only 9/31 (29%) pregnancies in women with karyotype 45,X were spontaneous, compared with 53/66 (80.3%) pregnancies in women with mosaic karyotype 45,X/46,XX (P < 0.0001). Women with mosaic karyotype 45,X/46,XX were younger at first pregnancy by 5.5-8.5 years compared with other Turner syndrome karyotype groups (P < 0.001), and more likely to have a spontaneous menarche (75.8% versus 50% or less, P = 0.008). There were 17 miscarriages, three terminations of pregnancy, two stillbirths and 105 live births. Two women had aortic dissection (2.5%); both were 45,X karyotype with bicuspid aortic valves and ovum donation pregnancies, one died. Another woman had an aortic root replacement within 6 months of delivery. Ten of 106 (9.4%) births with gestational age data were preterm and 22/96 (22.9%) singleton infants with birthweight/gestational age data weighed less than the tenth centile. The caesarean section rate was 72/107 (67.3%). In only 73/127 (57.4%) pregnancies was there documentation of cardiovascular imaging within the 24 months before conceiving. CONCLUSIONS: Pregnancy in women with Turner syndrome is associated with major maternal cardiovascular risks; these women deserve thorough cardiovascular assessment and counselling before assisted or spontaneous pregnancy managed by a specialist team. TWEETABLE ABSTRACT: Pregnancy in women with Turner syndrome is associated with an increased risk of aortic dissection.

The effect of mode of delivery and duration of labour on subsequent pregnancy outcomes: a retrospective cohort study.

OBJECTIVE: To assess whether delivery mode and duration of labour in a first labour of spontaneous onset is associated with gestational length, delivery mode and neonatal outcome in the subsequent pregnancy. STUDY DESIGN: Retrospective analysis of prospectively collected data. SETTING: 15 Maternity units in North West London (1988-2000). POPULATION: 30 840 women with spontaneous onset of labour in pregnancy 1 and a subsequent birth reported in the same database. METHODS: Assessment of outcomes by mode of delivery in pregnancy 1, restricting the analysis to the difference in the gestational length between pregnancy 1 and 2. MAIN OUTCOME MEASURES: Gestational length, mode of delivery and neonatal unit admission in pregnancy 2. RESULTS: Caesarean section (CS) in the first or second stage of labour in pregnancy 1 was associated with pregnancy 2 being a median of 5 and 8 days shorter and a preterm birth rate of 6.0% and 10.1%, respectively, whereas following a normal or instrumental vaginal birth in pregnancy 1, the median duration was similar, with preterm delivery rates of 4.5% and 3.9%. In all, 56.2% of women with a CS in pregnancy 1 had a repeat CS and 12.5% of their babies were admitted to a neonatal unit, compared with 5.3% of women with vaginal birth. Longer labours were associated with shorter gestations in pregnancy 2. CONCLUSIONS: Compared with vaginal birth, an emergency CS in the first-term pregnancy is associated with a shorter gestational length, increased rate of repeat CS and increased risk of NNU admission in the next pregnancy. TWEETABLE ABSTRACT: An emergency caesarean section in the first-term pregnancy affects the duration and outcome of the next pregnancy.

Impact of changes to national UK Guidance on testing for gestational diabetes screening during a pandemic: a single-centre observational study.

OBJECTIVE: To examine the differences in detection rate for gestational diabetes (GDM) comparing the methodology recommended by the National Institute for Health and Clinical Excellence (NICE) compared with testing described as appropriate during the Covid-19 pandemic by the Royal College of Obstetricians and Gynaecologists (RCOG). DESIGN: Cohort study of women delivering between 1 January 2016 and 1 July 2020. SETTING: London Teaching Hospital. POPULATION: All women delivering between 1 January 2016 and 13 May 2020 and follow up of women screening negative between 1 April 2020 and 13 May 2020. METHODS: Retrospective study of prospectively collected data. MAIN OUTCOME MEASURES: Detection rate of gestational diabetes. RESULTS: Using the RCOG guidance, the overall rate of women identified as having gestational diabetes fell from 7.7% (1853/24168) to 4.2% (35/831)(P = 0.0003). Of 230 women who tested negative according to the RCOG criteria from 1 April to 13 May but who subsequently had an oral glucose tolerance test, 47 (20.4%) were diagnosed as having gestational diabetes according to the NICE criteria. CONCLUSIONS: In our setting, the RCOG Covid-19 gestational diabetes screening regime failed to detect 47 of 82 (57%) women subsequently identified as gestational diabetics, and therefore cannot be recommended for general use. TWEETABLE ABSTRACT: Screening for GDM using RCOG Covid criteria reduced detection rates.

Seasonal and SARS-CoV-2 pandemic changes in the incidence of gestational diabetes.

OBJECTIVE: To test the hypothesis that there is seasonal variation in the rates of gestational diabetes (GDM) diagnosed using a 2-hour oral glucose tolerance test. DESIGN: Monthly assessment of the percentage of women screened from 1 April 2016 to the 31 December 2020 who were diagnosed as having gestational diabetes. SETTING: London teaching hospital. POPULATION: 28 128 women receiving antenatal care between 1 April 2016 and 31 December 2020. METHODS: Retrospective study of prospectively collected data. MAIN OUTCOME MEASURES: Proportion of women screened diagnosed as having gestational diabetes. RESULTS: The mean (SD) percentage of women diagnosed with GDM was 14.78 (2.24) in summer (June, July, August) compared with 11.23 (1.62) in winter (P < 0.001), 12.13 (1.94) in spring (P = 0.002) and 11.88 (2.67) in autumn (P = 0.003). There was a highly significant positive correlation of the percentage testing positive for GDM with the mean maximum monthly temperature (R2  = 0.248, P < 0.001). There was a statistically significant 33.8% increase in the proportion of GDM diagnoses from June 2020 onwards, possibly related to a reduction in exercise secondary to the Covid-19 pandemic. CONCLUSIONS: There is a 23.3% higher rate of GDM diagnoses in the warmer summer months. There has been a 33.8% rise in GDM diagnoses associated with the Covid-19 pandemic. TWEETABLE ABSTRACT: Rates of GDM are higher in summer and since the onset of the Covid-19 pandemic.

Pregnancy outcomes in women with primary biliary cholangitis and primary sclerosing cholangitis: a retrospective cohort study.

OBJECTIVE: To determine maternal, obstetric and neonatal outcomes in a cohort of women with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). DESIGN: Retrospective cohort study. SETTING: Ten specialist centres managing pregnant women with liver disease. POPULATION: Women with a diagnosis of PBC and PSC and a pregnancy of ≥20 completed weeks of gestation. METHODS: Retrospective case notes review. MAIN OUTCOME MEASURES: Adverse outcomes were defined as: maternal - development of ascites, variceal bleeding, encephalopathy and jaundice; obstetric events - gestational hypertension, pre-eclampsia and postpartum haemorrhage; and neonatal - stillbirth, preterm delivery and admission to neonatal unit. The relationship of alanine transferase (ALT) and bile acid levels with gestation at delivery was studied. RESULTS: The first recorded pregnancies of 34 women with PSC and 27 women with PBC were analysed. There were 60 live births and one intrapartum stillbirth that did not occur in the context of maternal cholestasis. The overall median gestation of delivery was 38 weeks but the rate of preterm birth was 28% (17/61 deliveries), 76% (13/17) of which were spontaneous. Gestation at birth negatively correlated with maternal serum ALT concentration at booking (P = 0.017) and serum bile acid concentration during pregnancy (P = 0.016). There were no other significant correlations and maternal and neonatal outcomes were good. CONCLUSIONS: Pregnancy in PBC and PSC is well tolerated, but women should be counselled regarding the increased risk of preterm birth. Measurement of maternal ALT and bile acids may help identify women at risk of preterm delivery. TWEETABLE ABSTRACT: Pregnancy in women with PBC and PSC is well tolerated; however, rates of preterm birth are high and are related to maternal bile acid levels.

Computerised analysis of intrapartum fetal heart rate patterns and adverse outcomes in the INFANT trial.

OBJECTIVE: To assess if a computerised decision support system reliably identified abnormal fetal heart rate (FHR) patterns in fetuses with adverse neonatal outcomes in the INFANT trial, and whether its use reduced substandard care. DESIGN: Prospective cohort study within a randomised controlled trial. SETTING: Twenty-four maternity units in the UK and Ireland. POPULATION OR SAMPLE: A total of 46 614 labours between January 6 2010 and August 31 2013 in the INFANT trial. METHODS: Panel review of intrapartum and neonatal care in infants with adverse outcome, and an assessment of the effectiveness of computerised interpretation of fetal heart rate in reducing substandard care. Descriptive analysis of other factors associated with adverse outcome. MAIN OUTCOME MEASURES: Incidence and detection rate of abnormal fetal heart rate patterns, other characteristics associated with perinatal adverse outcome, and frequency of substandard care. RESULTS: Computer interpretation of FHR patterns was deemed to be completely valid in only 24 of 71 (33.8%) cases of adverse outcome. On a scale of 0-10 (completely invalid to completely valid), 28 cases (39.4%) had a score of 6 or less, mainly due to lack of recognition of decelerations (15 cases), or reduced variability (seven cases), or failure to recognise tachysystole (five cases). There were multiple associated factors that modified the clinical assessment of FHR patterns. There was substandard care in 45/71 cases (63%). CONCLUSION: A significant proportion of abnormal fetal heart rate patterns were not detected accurately by computer analysis, and its use did not reduce the incidence of substandard care. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme (project number 06.38.01). TWEETABLE ABSTRACT: Improved recognition of abnormal fetal heart rate patterns is insufficient to reduce the incidence of substandard care.

Maternal and fetal outcomes in pregnancies complicated by the inherited aortopathy Loeys-Dietz syndrome.

OBJECTIVE: Pregnancies in women with Loeys-Dietz syndrome (LDS) are rare and are typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited. DESIGN: A retrospective cohort study. SETTING: Eight specialist UK centres. SAMPLE: Pregnant women with LDS. METHODS: Data was collated on cardiac, obstetric, and neonatal outcomes. MAIN OUTCOME MEASURES: Maternal and perinatal outcomes in pregnancies complicated by LDS. RESULTS: Twenty pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy, and 18 livebirths. In eight women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In four women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). In all, 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery. CONCLUSION: Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit. TWEETABLE ABSTRACT: Pregnancy outcomes in women with Loeys-Dietz syndrome.

Maternal cardiac and obstetric performance in consecutive pregnancies in women with heart disease.

OBJECTIVE: Second pregnancies are usually less complicated than first pregnancies, and have a better outcome in terms of fetal growth. We studied a group of women with heart disease to assess whether their second pregnancy was less complicated and resulted in a larger baby. DESIGN: Retrospective case control study. SETTING: Tertiary referral academic obstetric unit. POPULATION: First and second pregnancies in 77 women with congenital and acquired heart disease and in 154 control women were identified. METHODS: Data were collected from medical and obstetric records. MAIN OUTCOME MEASURES: Cardiac complications, obstetric complications, intra-partum events, birthweight and perinatal complications. RESULTS: The rate of obstetric complication was greater in first pregnancies in both the heart disease and the control groups (38% versus 26%, cf. 20% versus 17%). In the heart disease group, the rate of cardiac complications was similar in first and second pregnancies (9% versus 6%). Overall, significantly more perinatal complications were seen in the heart disease group, with no significant difference between first and second pregnancies (36% versus 27%, cf. 14% versus 12%). Median birthweight was significantly higher in second pregnancies in the control group (3308 versus 3519 g P < 0.001), but not significantly different between pregnancies in the heart disease group (3014 versus 3133 g, P = 0.19). CONCLUSIONS: This case control study demonstrates that women with mild to moderate heart disease have similar pregnancy outcomes in consecutive pregnancies. However, while the median birthweight was higher in the control second pregnancies, it was not increased in the women with heart disease. TWEETABLE ABSTRACT: A study of women with heart disease to assess whether their second pregnancy was less complicated.

Marfan syndrome and pregnancy: maternal and neonatal outcomes.

OBJECTIVE: To report outcomes in a recent series of pregnancies in women with Marfan syndrome (MFS). DESIGN: Retrospective case note review. SETTING: Tertiary referral unit (Chelsea and Westminster and Royal Brompton Hospitals). SAMPLE: Twenty-nine pregnancies in 21 women with MFS between 1995 and 2010. METHODS: Multidisciplinary review of case records. MAIN OUTCOME MEASURES: Maternal and neonatal mortality and morbidity of patients with MFS and healthy controls. RESULTS: There were no maternal deaths. Significant cardiac complications occurred in five pregnancies (17%): one woman experienced a type-A aortic dissection; two women required cardiac surgery within 6 months of delivery; and a further two women developed impaired left ventricular function during the pregnancy. Women with MFS were also more likely to have obstetric complications (OR 3.29, 95% CI 1.30-8.34), the most frequent of which was postpartum haemorrhage (OR 8.46, 95% CI 2.52-28.38). There were no perinatal deaths, although babies born to mothers with MFS were delivered significantly earlier than those born to the control group (median 39 versus 40 weeks of gestation, Mann-Whitney U-test, P = 0.04). These babies were also significantly more likely to be small for gestational age (24% in the MFS group versus 6% in the controls; OR 4.95, 95% CI 1.58-15.55). CONCLUSIONS: Pregnancy in women with MFS continues to be associated with significant rates of maternal, fetal, and neonatal complications. Effective pre-pregnancy counselling and meticulous surveillance during pregnancy, delivery, and the puerperium by an experienced multidisciplinary team are warranted for women with MFS.

The effect of maternal characteristics and gestational diabetes on birthweight.

OBJECTIVE: To examine the effect of maternal characteristics, including advancing maternal age, body mass index (BMI), racial origin and development of gestational diabetes mellitus (GDM), on birthweight and the interactions between these factors. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Fifteen maternity units in North West London, between 1988 and 2000. POPULATION: A cohort of 130 549 pregnant women. METHODS: Multivariate regression analysis. OUTCOME MEASURES: Birthweight z-scores in non-GDM and GDM groups within three main racial groups (white European, black and South Asian women). RESULTS: Babies born to women with GDM were heavier compared with those born to women with no GDM in all racial groups. In black women with GDM the birthweight z-scores were 0.805 higher, in South Asian women the scores were 0.618 higher and in white European women the scores were 0.437 higher, compared with the respective non-GDM group (P < 0.001 for both comparisons versus white European women), and these differences were much greater at high rather than at low maternal BMIs. Advancing maternal age, increasing BMI, highest diastolic blood pressure, Castair's index, racial group and presence of GDM or smoking were each, individually, significantly associated with birthweight z-scores (P < 0.001 for all variables). After adjusting for possible confounding factors, BMI was positively associated with birthweight z-scores within all racial groups (P < 0.001 for all), irrespective of glycaemic status, but its effect was much greater in women with GDM, particularly in those of non-White origin. After adjusting for possible confounding factors, advancing maternal age was only positively associated with birthweight in women of white European and South Asian racial origin who did not suffer from GDM (P < 0.001 for both). CONCLUSION: Gestational diabetes mellitus strongly accentuates the effect of maternal BMI on birthweight, especially within non-white populations.

An analysis of the interrelationship between maternal age, body mass index and racial origin in the development of gestational diabetes mellitus.

OBJECTIVE: To examine the individual association between advancing maternal age, body mass index (BMI) and racial origin with the development of gestational diabetes mellitus (GDM) and the interaction between these factors. DESIGN: Retrospective study. SETTING: Fifteen maternity units in northwest London between 1988 and 2000. POPULATION: The study included 1688 women who developed GDM and 172,632 who did not. All women were nulliparous. BMI was calculated at first antenatal visit and maternal age and racial origin (White European, Black African, Black Caribbean or South Asian) were self-reported. METHODS: Binary logistic regression analysis. MAIN OUTCOME MEASURES: Development of GDM within each racial group. RESULTS: There was a strong positive association between advancing maternal age and increasing BMI, individually, and the development of GDM (P < 0.01 for both). Compared with White Europeans aged 20-24 years, the odds ratios for GDM development were significantly higher in women older than 30 years if they were White Europeans (P < 0.001), older than 25 years if they were Black Africans (P < 0.001) and older than 20 years if they were South Asians (P < 0.001). The odds ratios for GDM development were significantly higher in Black Africans and South Asians (P < 0.001 for both) irrespective of BMI, compared with White Europeans with normal BMI. CONCLUSION: Maternal age and BMI interact with racial group in relation to the prevalence of GDM. Both factors are important in the development of GDM, particularly so in Black African and South Asian women.

Pulmonary hypertension and pregnancy--a review of 12 pregnancies in nine women.

OBJECTIVE: To report outcomes in a recent series of pregnancies in women with pulmonary hypertension (PH). DESIGN: Retrospective case note review. SETTING: Tertiary referral unit (Chelsea and Westminster and Royal Brompton Hospitals). SAMPLE: Twelve pregnancies in nine women with PH between 1995 and 2010. METHODS: Multidisciplinary review of case records. MAIN OUTCOME MEASURES: Maternal and neonatal mortality and morbidity. RESULTS: There were two maternal deaths (1995 and 1998), one related to pre-eclampsia and one to arrhythmia. Maternal morbidity included postpartum haemorrhage (five cases), and one post-caesarean evacuation of a wound haematoma. There were no perinatal deaths, nine live births and three first-trimester miscarriages. Mean birthweight was 2197 g, mean gestational age was 34 weeks (range 26-39), and mean birthweight centile was 36 (range 5-60). Five babies required admission to the neonatal intensive care unit, but were all eventually discharged home. All women were delivered by caesarean section (seven elective and two emergency deliveries), under general anaesthetic except for one emergency and one elective caesarean performed under regional block. CONCLUSIONS: Maternal and fetal outcomes for women with PH may be improving. However, the risk of maternal mortality remains significant, so that early and effective counselling about contraceptive options and pregnancy risks should continue to play a major role in the management of such women when they reach reproductive maturity.