Abstract
1 Hemophagocytic lymphohistiocytosis in pregnancy evolving towards fulminant hepatitis: A case report and literature review
1Department of Medicine, McGill University, Montreal, Québec, Canada
2Department of Obstetrics and Gynecology, Obstetric Medicine Division, CHU Sainte-Justine, Université de Montréal, Montreal, Québec, Canada
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening inflammatory disorder characterized by excessive immune activation and phagocytosis of normal hematopoietic cells.
A previously healthy 34-year-old woman presented at 31 weeks of gestation with migraines and abdominal pain. She was found to have fever, pancytopenia, elevated alanine aminotransferase and lactate dehydrogenase, and splenomegaly on ultrasound.
An extensive infectious work-up including blood cultures, Ebstein–Barr virus, cytomegalovirus, parvovirus B19 and hepatitis serologies was negative. Ferritin level was 4000 ng/mL. A bone marrow biopsy showed hypocellularity, without hemophagocytosis.
Within five days, the ferritin went from 1800 ng/mL to 18,000 ng/mL and the woman developed fulminant liver failure. High-dose intravenous steroids were initiated for suspected autoimmune or inflammatory disorder. An urgent C-section was performed for fetal distress. The diagnosis of HLH was confirmed by liver biopsy post-partum. She was treated with dexamethasone and etoposide and improved rapidly. Etoposide was later changed to anakinra, an interleukin-1 inhibitor.
There are 37 reported cases of HLH in pregnancy, which have been associated with infections (41%), rheumatologic conditions (22%), lymphomas (5%), while approximately 30% had no identifiable cause or trigger. There is no established consensus regarding the treatment of HLH in pregnancy, but early recognition of signs and symptoms is essential to avoid treatment delay. The need for termination of pregnancy remains controversial, with important considerations including maternal health, fetal prematurity and treatment toxicity. Our case is the first to describe evolution towards fulminant hepatitis and the use of anakinra as an alternative agent to allow breastfeeding.
2 Hypercalcemia in pregnancy: A case of exogenous calcium intoxication
1Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
Abstract
Milk-alkali syndrome (MAS) is a relatively uncommon etiology of hypercalcemia caused by ingestion of excess calcium and absorbable alkali. The triad of hypercalcemia, renal dysfunction, and metabolic alkalosis that characterizes MAS has recently made a resurgence with the increased use of calcium carbonate. Pregnant women are particularly susceptible to developing MAS due to an increase in intestinal calcium absorption, resulting in complications which include hyperemesis, confusion, acute renal injury, nephrolithiasis, pancreatitis, and preeclampsia. Long-standing maternal hypercalcemia may result in intrauterine growth restriction, preterm delivery, fetal demise, low birth weight, and neonatal tetany.
From the literature, only 10 cases of MAS have previously been described in pregnancy. The mainstays of MAS treatment during pregnancy involved fluid resuscitation with or without furosemide and bisphosphonate use.
We report a case of hypercalcemia in pregnancy in a 37-year-old woman at 38 weeks of gestation due to excess exogenous calcium intake (4000 mg as Tums, and 1.5 L of milk for 7–10 days) for the treatment of severe gastroesophageal reflux disease. Her initial ionized calcium level was 1.87 mmol/L, and creatinine was 83 µmol/L. Both levels normalized with IV fluids and a single dose of calcitonin 400 IU sc. Initial newborn calcium level was 2.95 mmol/L, but resolved over 12 h with no apparent sequelae.
MAS should be considered in the differential of hypercalcemia during pregnancy, and calcitonin could be considered first line due to its safety profile in pregnancy. Early recognition and treatment is crucial in preventing serious maternal, fetal, and neonatal morbidity.
3 Comparison of postpartum HbA1c to fructosamine in normal pregnancy
1Drexel University College of Medicine. Hahnemann University Hospital, Philadelphia, PA, USA
2Hackensack Meridian Seton Hall School of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
Abstract
Introduction
Fructosamine and HbA1c are convenient tests to assess postpartum dysglycemia. Breastfeeding can lower postpartum oral glucose tolerance test results by 5%. As similar data do not exist regarding fructosamine, we evaluated the association.
Methods
Women with uncomplicated pregnancies were given a questionnaire and had blood drawn at their postpartum visit. The primary outcome was to determine if breastfeeding was associated with fructosamine 5% lower than the non-breastfeeding group. The secondary outcome was to determine if breastfeeding would lower HbA1c values.
Results
The breastfeeding (BF, n = 22) and non-breastfeeding women (NBF, n = 28) were demographically similar, including postpartum weight loss (21.5 vs. 18 lbs). The respective values among BF and NBF women were: Fructosamine 2.20 vs. 2.21 mmol/L; HbA1c 5.2 vs. 5.2%. Only 2/7 women with HbA1c ≥ 5.7% had an abnormal fructosamine.
Conclusion
In women with normal pregnancies, breastfeeding was not associated with lower levels of postpartum fructosamine or HbA1c. Future research to improve screening for persistent postpartum dysglycemia in high-risk populations can utilize these tests without concern that results will be confounded by breastfeeding.
4 PRES or preeclampsia-related encephalopathy syndrome?
1Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
Abstract
Background
Posterior reversible encephalopathy syndrome (PRES) is a radiologically diagnosed severe complication of preeclampsia that warrants delivery. The occurrence of PRES in preeclamptic women has been described, but the frequency with which this occurs is uncertain. Given the clinical implication associated with the diagnosis of PRES, we undertook a systematic review of the literature to further elucidate this condition.
Objectives
The primary objective of our study is to determine the frequency and presentation of PRES, identified through neuroimaging, in association with eclampsia and severe preeclampsia.
Study design
A systematic review of the literature was conducted to identify English language articles on PRES presenting in pregnant women with severe preeclampsia and eclampsia. We included articles that reported on six or more cases of pregnant women with eclampsia or severe preeclampsia, who underwent neuroimaging, during pregnancy and/or up to six weeks after delivery.
Results
We identified 27 eligible studies presenting data on 1444 women with eclampsia or severe preeclampsia who underwent neuroimaging, among them, 837 women with eclampsia and 607 women with severe preeclampsia. Magnetic resonance imaging and computed tomography were both used to diagnose PRES. In 327 unselected eclamptic women who had neuroimaging, 163 (49.8%) were diagnosed with PRES. Of the 61 unselected women with severe pre-eclampsia who had imaging, 10 (16.39%) women had PRES. Regions of the brain affected with PRES include: occipital (82.3%), parietal (65.9%), frontal (31%), infratemporal (25.1%), and cerebellum (18.6%).
Conclusion
PRES is a common finding in eclamptic and severely preeclamptic women who undergo neuroimaging – up to 50% with eclampsia and 16% with severe preeclampsia. As the diagnosis of PRES implies imminent need for delivery, the role of neuroimaging in women with severe preeclampsia requires further evaluation.
5 A case of undiagnosed secondary hypertension in pregnancy
1Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
Abstract
Background
Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic vascular disease which may manifest as arterial stenosis, occlusion, aneurysm or dissection. FMD most commonly affects the renal arteries, resulting in renal artery stenosis which may manifest as hypertension.1,2 Limited information on FMD in pregnancy is available in literature.
Discussion
Hypertension in pregnancy is a leading cause of maternal and fetal morbidity. 3 The current case demonstrates numerous complications of secondary hypertension in pregnancy. Pregnancy is an important opportunity to address chronic medical issues. As per the Hypertension Canada guidelines, women presenting at lesser than 30 years of age with hypertension should be investigated for fibromuscular dysplasia-related renal artery stenosis. 4
References
6 Gastric perforation after caesarean delivery: An unintended consequence of the opioid epidemic
1Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, USA
Abstract
Learning objectives
(1) Review gastric perforation as a rare complication of non-steroidal anti-inflammatory drug (NSAID) use after caesarean delivery. (2) Understand risks of NSAID overuse in response to opioid epidemic.
Discussion
In response to the current opioid epidemic, there has been a growing antipathy toward opioid use irrespective of need or indication. Non-opioid based pain management frequently relies on NSAIDs. While widely available and generally considered safe, NSAIDs have been associated with gastrointestinal complications including perforation. Opioids remain an important and safe component of postoperative pain management for most women. More than 95% of post-operative women use opioids without developing substance use disorder. This case should serve as a cautionary tale to those promoting an abrupt change in the management of post-operative pain.
7 Optimizing high-fidelity simulation for teaching Obstetric Medicine concepts: A curriculum mapping and development project
1Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
Abstract
Background
With the change in the structure of Internal Medicine training in Canada to competence-by-design, residents must demonstrate competence in Obstetric Medicine consultation. High-fidelity simulation offers a way to expose residents to this unique patient population in a safe environment. We have previously demonstrated the effectiveness of simulation in teaching the assessment of dyspnea in pregnancy. However, a single case does not adequately sample necessary competencies. Our objective is to create a comprehensive and Obstetric Medicine simulation curriculum for trainees.
Methods
With the Royal College of Physicians and Surgeons of Canada (RCPSC) Objectives of Training for Internal Medicine as a blueprint, we created simulation cases based on chart reviews of patient presentations. Objectives were reviewed by experts in simulation and Obstetric Medicine for appropriateness for simulation and content validity. Simulation cases were then piloted on PGY 4–5 Internal Medicine residents for content and revised accordingly.
Results
Nine simulation cases were created to address 15 Obstetric Medicine RCPSC objectives. Cases include dyspnea in pregnancy, venous thromboembolism, hypertensive disorders of pregnancy, cardiac disease, sepsis in pregnancy, thrombocytopenia, diabetes in pregnancy, and liver disease. Three cases were piloted on trainees over one month and a total of 35 h of simulation education has been delivered to date.
Conclusion
We have developed a comprehensive simulation curriculum to reflect the Obstetric Medicine objectives outlined by the RCPSC for Internal Medicine. Future directions include evaluating the effectiveness of our curriculum for teaching Obstetric Medicine to trainees and evaluating how stress and emotion affect learning in simulation.
8 Impact of an educational pamphlet on knowledge about future pregnancy and health risks after a pregnancy complicated by hypertension: A randomized controlled trial
1Obstetric Medicine, Division of Internal Medicine, Department of Medicine, CIUSSS de l’Estrie-Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
2Nephrology, Department of Medicine, CIUSSS de l’Estrie-Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
3Endocrinology, Department of Medicine, CIUSSS de l’Estrie-Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
4Perinatology, Department of Family Medicine, CIUSSS de l’Estrie-Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
5Obstretrics and Gynecology, CIUSSS de l’Estrie-Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
Abstract
Background
Hypertensive disorders of pregnancy (HDP) predispose to recurrence of these disorders in the next pregnancy and increase risks of future cardiovascular disease (CVD). Women need to be educated about strategies to modulate these risks in the post-partum period.
Purpose
To evaluate the effect of an educational pamphlet on knowledge, risk perception, and anxiety about the risks of HDP in the next pregnancy and the long-term risks after a pregnancy complicated by HDP compared to usual care.
Methods
At the HDP post-partum clinic, after medical counselling (routine care), all consenting participants first filled questionnaire #1 (demographic information, questions about knowledge/risk perception about risks of HDP, anxiety and satisfaction). Then, participants in the intervention group received an educational pamphlet. One month later, both groups answered questionnaire #2, evaluating the same aspects.
Results
There were 57 participants in the intervention group and 56 participants in the control group; 13% women did not answer the questionnaire #2. The knowledge score was better in the intervention group one month later, 27/31 versus 21/31 at baseline (p < 0.0001) and this score was better in the intervention group as compared to the control group at one month, 27/31 and 22/31, respectively (p < 0.0001). No difference was found in the score of the control group at baseline and one month. There was no difference in the perception of risks, nor anxiety scores.
Conclusion
The educational pamphlet increases women’s knowledge about future health risks without increasing anxiety, and might be helpful in promoting lifestyle changes necessary to modify these risks.
9 Severe malarial sepsis in pregnancy – An Australian case report
1Medical Obstetrics, Northern Health, Victoria, Australia
Abstract
Free of endemic malaria since 1981, malaria infection in Australia is rare (1.5 cases/100,000 in 2017); likely very rare in pregnancy (no Australian data; 0.02% of malaria cases in USA (2015)). Malaria in pregnancy more often follows a severe course, particularly in non-endemic regions, carrying substantial risks to mother and fetus. Complications include hypoglycaemia, pulmonary oedema, severe anaemia and secondary bacterial infection in the mother, and miscarriage, prematurity, growth restriction, congenital infection and perinatal death.
We describe the multidisciplinary management of a 20-year-old primigravid woman with plasmodium vivax malarial sepsis at 31 weeks of gestation, after returning to Melbourne from Pakistan. She presented in shock with BP 64/34 mmHg, HR 120 beats per minute, RR 45 breaths per minute and swinging fevers. Despite a clinical course complicated by anaemia, thrombocytopenia, secondary bacterial sepsis, oligohydramnios and fetal growth restriction, successful collaboration between medical obstetrics, ICU, infectious disease and obstetric teams facilitated her full recovery, and delivery of a healthy infant at 35 + 3/40.
Despite steady global decline in Malaria between 2000 and 2015, the WHO World Malaria report 2017 demonstrated stalled progress, with an increase of five million cases in 2016. With malaria rates soaring among some of Australia’s neighbours, emerging drug-resistance causing treatment failure in Asia, climate change affecting geographical movement of mosquito-borne infections and the anopheles mosquito present in Northern Australia, Australia is likely to encounter more malarial sepsis in pregnancy. With management complicated by disease severity and limited treatment options, multidisciplinary collaboration and a high index of suspicion are vital to enable early, effective treatment.
Bibliography
10 An unusual case of cardiac tamponade during third trimester of pregnancy
1Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University/Cooper Hospital, Camden, NJ, USA
Abstract
Background
Cardiac tamponade is a rare occurrence in pregnancy. 1 When complicated by an anterior mediastinal mass, significant physiologic and pathologic changes occur.2
Case
A 19-year-old G1P0 at 39 weeks presented with dyspnea, cough, and orthopnea with unstable vital signs. Imaging revealed a large pleural effusion and a large pericardial effusion consistent with cardiac tamponade. Despite attempts at thoracentesis and pericardiocentesis, she became progressively hypoxic with fetal distress, necessitating emergent caesarean delivery. Postpartum chest CT revealed a 15 cm anterior mediastinal mass diagnosed as primary mediastinal large B-cell lymphoma.
Conclusion
Rare causes of common symptoms in pregnancy result in delayed diagnosis. Although the median age for primary mediastinal large B-cell lymphoma is 30–40 years old, young age does not preclude the diagnosis.
References
11 NSAID use in the immediate postpartum period of women with preeclampsia
1Women & Infants Hospital, Providence, RI, USA
2Rhode Island Hospital, Providence, RI, USA
3UCSF Medical Center, San Francisco, CA, USA
Abstract
Objective
NSAIDs have been associated with the development of acute kidney injury (AKI), particularly in those with underlying renal compromise. Whether NSAIDs administered after delivery increase the incidence of AKI in women with preeclampsia (PEC) is unproven. Magnesium infusion, hemodynamic instability, and endothelial dysfunction in PEC all contribute to renal injury in these women. We conducted this study to evaluate whether administering NSAIDs to preeclamptic women in the immediate postpartum period is an added insult to injury resulting in elevated creatinine levels.
Study design
In this retrospective cohort study, we identified women who were diagnosed with preeclampsia either during pregnancy or the postpartum period who were admitted to Women and Infants Hospital in 2016 (N = 246). Demographics and clinical characteristics were recorded, including age, BMI, past history of hypertension or diabetes, mode of delivery, and laboratory data. Women without pre-delivery creatinine levels were excluded.
Results
Primary Outcome: first creatinine of admission vs. first creatinine postpartum
aFriedman test.
Conclusion
Our study shows that in the short term, repeated NSAIDs use did not result in sustained creatinine elevation in postpartum women with preeclampsia. Thus, NSAIDs use for postpartum analgesia should be safe even in preeclamptic women. However, close monitoring and follow-up is warranted as these women are still at increased risk of developing renal compromise.
12 Acute poisoning in pregnancy: A retrospective study from a province-wide poison centre
1Department of Medicine, University of Toronto, Toronto, Ontario, Canada
2Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
3Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
4Ontario Poison Centre, Hospital for Sick Children, Toronto, Ontario, Canada
5Division of Emergency Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
Abstract
Background
Poisoning in pregnancy can cause maternal and neonatal morbidity and mortality, but few data exist to detail such events. We describe poisonings in pregnant women captured by a large Canadian Poison Centre.
Methods
This retrospective study evaluated poisonings in pregnant women aged 12–60 years, reported to the Ontario Poison Centre, 2010 to 2017. Cases of reported poisoning were identified by querying the Poison Centre database for calls received, in which the patient was also reported to be pregnant. We collected patient demographics (age, trimester, call location), as well as information about the poisoning exposure (number and type of substances, route of exposure, reason for exposure, decontamination and treatment recommendations). Maternal age and trimester were each examined in relation to an intentional overdose in pregnancy.
Results
There were 1716 cases of poisoning in pregnancy, representing 0.28% of all 619,539 calls over an eight-year period. Median maternal age was 29 years (IQR = 25–33), and poisonings were most frequent in the second trimester of pregnancy (41%). Unintentional poisoning (n = 1397) accounted for 81% of all calls. Of the 18% of calls (n = 305) for intentional poisoning, 71% (n = 219) were suspected suicides. Analgesics, sedatives and antidepressants were the most common intentional exposures, whereas gases/vapors/fumes and cleaning solutions were the most common unintentional compounds. Intentional poisoning was more frequent in the first (OR = 2.64, 95% CI = 1.85–3.76) and second trimesters (OR = 1.61, 95% CI = 1.13–2.28), relative to third trimester. The associated risk of intentional poisoning was more likely in women aged ≤ 19 years (OR = 24.7, 95% CI = 6.94–87.89) and 20–29 years (OR = 4.29, 95% CI = 1.29–14.30), relative to women greater than 40 years old.
Conclusion
Intentional poisoning in pregnancy is most common among young women and in the first two trimesters. Population-based studies are needed to further examine risk factors for overdose, poisoning, and self-harm in pregnancy, as well as perinatal outcomes.
13 Is management of mild intrahepatic cholestasis of pregnancy associated with maternal and fetal complications?
1Department of Medicine, Division of Internal Medicine, Centre Universitaire de l’Université de Montreal (CHUM), Montreal, Quebec, Canada
2Department of Medicine, Division of Internal Medicine, CIUSSS de l’Estrie, Sherbrooke, Quebec, Canada
3Centre Hospitalier de l’Université de Montreal Research Center (CRCHUM), Montreal, Quebec, Canada
4Department of Obstetrics and Gynecology, CHUM, Montreal, Quebec, Canada
5Department of Obstetrics and Gynecology, Division of Obstetric Medicine, CHU Sainte Justine, Montreal, Quebec, Canada
Abstract
Intrahepatic cholestasis of pregnancy (ICP) is the most common liver disease diagnosed during pregnancy. Maternal outcomes are usually good, but ICP can lead to adverse fetal outcomes. Most centers induce all women diagnosed with ICP during the 37th week of pregnancy.
The primary aim of our study was to compare maternal and fetal outcomes in women with ICP and biliary acids levels lesser than 40 mmol/L with normal pregnancy.
This study was a multicenter retrospective cohort study that included all women with pruritus and bile acid levels greater than 10 mmol/L compared with normal pregnancy, between January 2012 and June 2018 in three teaching hospitals in Quebec.
Preliminary results based on two centers (82 ICP and 260 controls) show that composite maternal outcome (caesarean, caesarean during labor, induction of labor, assisted vaginal birth and postpartum hemorrhage) was higher (73% vs. 43%, p < 0.001) in the ICP group. The maternal composite outcome was mainly driven by the induction rate (69.5% vs. 34.6% p < 0.001). Caesarean during labor was not increased (7.3% vs. 11.9%). Prematurity was higher in the ICP group (21.9% vs. 2.7%, p < 0.001). Iatrogenic prematurity was 10.9% vs. 0.3%. The rate of meconium staining, fetal distress, neonatal admission and stillbirth were unchanged in women with ICP.
The meta-analysis by Ovadia et al. 1 showed that there seem to be a low rate of stillbirth in that population when delivered up to 39 weeks. Induction after 37 weeks should be recommended to prevent iatrogenic prematurity in that population.
Reference
14 Management and outcomes of MODY in pregnancy
1Division of Endocrinology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
2Division of General Internal Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
Abstract
Background and objectives
Maturity-onset diabetes of the young (MODY) is a group of monogenic disorders that accounts for 1–5% of diabetes. The most common mutations are those in the HNF-1 alpha and in the GCK genes. Although the management of MODY is well established, no guidelines currently exist for management during pregnancy. MODY is often under-diagnosed, and clinical experience during pregnancy is lacking. Both maternal glycemic control and fetal mutation status are factors that may influence outcomes during pregnancy. The primary aim of this project was to describe cases of MODY during pregnancy to highlight the clinical implications of management of this disorder during pregnancy.
Methods
The Ottawa Hospital is the primary referral center for high-risk obstetric women, including diabetes in pregnancy in the Ottawa, Canada. Referrals between 2008 and 2018 were reviewed and a case series of three women and five pregnancies is described. A literature review of MODY in pregnancy, together with the illustrative cases, is used to highlight clinical considerations unique to MODY in pregnancy.
Results
We describe five pregnancies with MODY-2 (GCK mutation) and MODY-3 (HNF-1-alpha mutation). Important issues identified included monitoring of fetal growth and individualization of maternal glycemic control particularly in cases where fetal mutation status is unknown. There were no cases of macrosomia or severe growth restriction.
Conclusions
Management of MODY in pregnancy is challenging and there is little evidence to guide recommendations. Fetal growth can be used to guide the management of maternal glycemic targets when fetal mutation status is unknown.
15 Postpartum thromboprophylaxis prescribing practices in caesarean section women at Mount Sinai Hospital, Toronto
1Department of Medicine, The Scarborough Hospital, Toronto, Ontario, Canada
2Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
3Department of Medicine, University of Toronto, Toronto, Ontario, Canada
Abstract
Background and purpose
Pulmonary embolism is a significant cause of postpartum morbidity and mortality. According to the Society of Obstetricians and Gynecologists of Canada, an absolute postpartum risk of greater than 1% is often used to determine thromboprophylaxis following caesarean section (C/S); however, determining the individual magnitude of risk is challenging. At Mount Sinai Hospital (MSH), a decision support by the computerized physician order entry was developed and launched in July 2016, to identify women at increased risk of postpartum thrombosis and assist in ordering thromboprophylaxis. Our goal in this study was to investigate whether the decision support increased the proportion of eligible women who received thromboprophylaxis.
Methods
We conducted a retrospective study at MSH from 1 July 2015 to 31 July 2017 of women with BMIs greater than 40 kg/m2 who had a C/S. The decision support directs the prescriber to consider thromboprophylaxis in such women for up to six weeks.
Results
We reviewed 255 charts, with 227 meeting criteria for VTE prophylaxis. The average BMI was 48.9 kg/m2 prior to, and 45.0 kg/m2 following release of the decision support (p = 0.01). Prior to July 2016, 20 out of 109 (18.3%) of these women had documented thromboprophylaxis, compared to 28 of 118 (23.7%) following release of the decision support (p = 0.321).
Conclusions
The decision support provided a non-statistical increase in prescribing practices in a small cohort of women. Future studies need to address the suboptimal adherence to the decision support, and to investigate barriers to initiating thromboprophylaxis.
16 Primary autoimmune myelofibrosis: A unique presentation of macrocytic anemia in pregnancy
1Department of Obstetric Medicine, Brown University, Providence, RI, USA
2Department of Hematology, Brown University, Providence, RI, USA
3Department of Rheumatology, Brown University, Providence, RI, USA
Abstract
Anemia is a frequent finding during pregnancy. However, the presence of persistent macrocytic anemia warrants further investigation for underlying medical conditions.
We present a case of a 29-year-old nulliparous woman with severe macrocytic anemia during pregnancy. Her past medical history was notable for extensive rheumatologic evaluation due to symptoms of chronic fatigue, diffuse arthralgia, and oral ulcers since adolescence. Historic records revealed presence of both macrocytic anemia and mild leukopenia with lymphocytic predominance prior to pregnancy. During pregnancy, her macrocytic anemia worsened but her leukocyte count increased to normal range while maintaining relative lymphocytosis. Laboratory testing showed elevated anti-nuclear antibody and rheumatoid factor. Subsequent bone marrow biopsy revealed myelofibrosis with increased lymphoid aggregates. Genetic testing was negative for JAK2, CALR, or MPL mutation. Based on this distinct constellation of clinicopathological findings, the woman was diagnosed with primary autoimmune myelofibrosis and treated with a course of high-dose oral corticosteroids.
Autoimmune myelofibrosis is an uncommon etiology of bone marrow fibrosis that is either secondary to known autoimmune disease, or primary with nonspecific serologic findings of autoimmunity. It is important to distinguish primary autoimmune myelofibrosis from primary myelofibrosis as the former is benign and portends a favorable prognosis. Bone marrow biopsy is of paramount diagnostic value and should not be delayed or avoided due to pregnancy. The rarity of autoimmune myelofibrosis can pose a diagnostic challenge, but the close clinical care and monitoring during pregnancy presents a unique opportunity for thorough evaluation of anemia with atypical features.
17 Home blood pressure monitoring in the diagnosis and treatment of hypertension in pregnancy: A systematic review
1Department of Medicine, Division of General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
2Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
Abstract
Background
Home blood pressure monitoring (HBPM) is commonly used by non-pregnant adults for the diagnosis and management of hypertension. Pregnant women are frequently using HBPM; however, limited knowledge exists on how often to measure home BP, and diagnostic and treatment thresholds in pregnancy. The objective of our systematic review is to assess how HBPM in pregnancy is performed, and equivalent home BP (HBP) thresholds from traditional office BP (OBP) measurement for the diagnosis of hypertension in pregnancy.
Methods
MEDLINE, Embase and CENTRAL databases were searched (inception – August 2018) for observational studies and randomized controlled trials evaluating HBPM with OBP measurements in pregnant women. We identified 15 trials that assessed HBPM with OBP (N = 2030 pregnant women).
Results
We observed wide variation in practice patterns on how HBP was measured in pregnant women. Only 25.6% of studies utilized validated HBP devices. HBP was measured between 3 and 36 times per week with variable compliance between 11.2% and 92.0%. Equivalent HBP to OBP of 140/90 mm Hg in the third trimester ranged from 118 to 143 or 76 to 92 mm Hg depending on patient population and methodology.
Conclusions
Inconsistencies exist on how HBP measurements are performed in pregnancy. Validated HBP monitors for pregnancy should be used to ensure accurate and reliable BP measurements. Patient education is important to ensure proper measurement techniques, and clear instructions need to be given to women to seek medical attention. Further studies are necessary to assess timing and frequency of HBP measurements, diagnostic and treatment thresholds for HBP in pregnancy and effect on maternal and neonatal outcomes.