Severe Haemolytic Disease of Foetus and Newborn due to Anti-c Alloimmunisation in a Multiparous Malay Woman: A case study

Severe haemolytic disease of foetus and newborn (HDFN) is commonly caused by anti-D, anti-c and anti-K alloimmunisation. However, anti-c associated HDFN are infrequent because the majority of infants are relatively often c-negative. This case report describes a severe HDFN due to anti-c alloimmunisation in a multiparous Rhesus D positive mother. The baby was delivered prematurely at 32 weeks of gestation and unable to survive due to hydrops foetalis. Failure to detect anti-c alloimmunisation at the early antenatal period and unknown previous RBC alloimmunisation status were the main reasons for poorly suspicion of HDFN, which lead to improper foetal management and end up with foetal loss. Thus, routine antenatal RBC antibody screening during the early antenatal period is recommended for every pregnant woman with a history of HDFN or at risk for alloimmunisation for early detection and management of HDFN to prevent severe related morbidity or mortality.

High-risk factors for adverse pregnancy outcomes in systemic lupus erythaematosus: a retrospective study of a Chinese population

ObjectiveTo clarify high-risk factors for adverse pregnancy outcomes (APOs) in systemic lupus erythaematosus (SLE).DesignA retrospective chart review study.SettingData were collected in a tertiary medical centre, Shanghai, China, from November 2010 to December 2018.ParticipantsA total of 513 pregnancies with SLE were retrospectively analysed. Twenty-seven patients who underwent artificial abortions due to personal reasons were excluded.Primary outcome measuresAPOs were primary outcomes, including foetal loss, premature birth, small for gestational age (SGA), asphyxia neonatorum, composite foetal APOs and hypertensive disorders of pregnancy (HDP). Multivariable logistic regression and Spearman correlation analysis were performed to determine the risk factors for APOs in SLE.ResultsRisk factors for foetal loss included prepregnancy hypertension, hypocomplementaemia-C3, anticardiolipin antibodies-IgM positivity and disease flares during pregnancy. Risk factors for premature birth included disease flares, use of immunosuppressive agents and HDP. Moreover, twin pregnancy, disease flares and HDP were risk factors for SGA, and prepregnancy hypertension was an independent risk factor for asphyxia neonatorum. Independent risk factors for composite foetal APOs included twin pregnancy, prepregnancy hypertension, disease flares during pregnancy, HDP, hypocomplementaemia-C3 and the use of immunosuppressive agents. Risk factors for SLE complicated with HDP included prepregnancy hypertension, renal disorders and thrombocytopaenia. Conversely, the use of aspirin was a protective factor against foetal loss and premature birth. The ds-DNA value had a low diagnostic value for APOs, whereas the extent of complement reduction may predict the incidence of composite foetal APOs and foetal loss. Proteinuria occurring in the first 20 gestational weeks may lead to APOs.ConclusionEstablished risk factors for each APO were identified in this study. Indicators with more predictive significance have been screened out from conventional indicators, which may help clinicians predict the pregnancy outcome of patients with SLE more accurately and minimise the incidence of APOs.

Is It Necessary to Perform Pre Operative Upper Gastrointestinal Endoscopy in Elective Symptomatic Cholelithasis?

Objective: Is it necessary to perform pre operative upper gastrointestinal endoscopy in elective symptomatic cholelithasis? Study Design: Prospective observational study. Place and Duration of Study: This study was conducted at surgical departments of Services Hospital, Ruth PFAHU, Civil Hospital Karachi, Shaheed Benazir Bhutto Medical College, Lyari Karachi and Liaquat University Of Medical and Health Sciences, Jamshoro from July 2018 to December 2019. Methodology: Study consisted of 382 patients. All patients were subjected to Upper Gastrointestinal Endoscopy 24 to 48 hours before cholecystectomy followed by biopsy were obtained for histopathology if required. Those patients not willing for surgery, General anesthesia problem, pregnant ladies due to risk of foetal loss, carcinoma of gall bladder, stone in CBD and obstructive jaundice were excluded. Results: Out of the 382 patients, 66(17.27%) males and 316(82.72%) females with mean age of study population was 46.10 ± 6.31 years (22 to 65 years). Patients were present typical pain in 146(38.21%) cases and atypical pain in 236(61.78%) cases. Pre operative upper gastrointestinal endoscopy findings revealed Esophagitis in 22(5.75%) cases, GERD in 26(6.80%) cases, gastritis in 88(23.03%), gastric ulcer 49(12.82%), duodenal ulcer in 39(10.20%), polps 21(5.49%) and carcinoma of stomach 9(2.35%). Out of 236(61.78%) cases with atypical pain had persistence of symptoms in 141 (59.74%) cases upto four months. Conclusion: We conclude that upper gastrointestinal endoscopy preoperatively for gallstone disease should be performed. So that preoperatively atypical symptoms are evaluate and taken care of, and patients is fully informed and also treated for associated conditions.

Haem oxygenases play a pivotal role in placental physiology and pathology

BACKGROUND Haem oxygenases (HO) catabolise haem, which is the prosthetic group of numerous haemoproteins. Thus, multiple primary cellular pathways and functions rely on haem availability. HO exists in two isoforms, both expressed in the placenta, namely HO-1 and HO-2, the first being inducible. Haem oxygenases, particularly HO-1, have garnered specific interest in the field of physiological and pathological placental function. These enzymes mediate haem degradation by cleaving the alpha methene bridge to produce biliverdin, which is subsequently converted to bilirubin, carbon monoxide and iron. HO-1 has anti-inflammatory and antioxidant activities. SEARCH METHODS An initial literature analysis was performed using PubMed on 3 October 2018 using key terms such as ‘haem oxygenase and pregnancy’, ‘haem oxygenase and placenta’, ‘HO-1 and pregnancy’, ‘HO-1 and placenta’, ‘HO and placenta’, ‘HO and pregnancy’, ‘genetic variant and HO’, ‘CO and pregnancy’, ‘CO and placenta’, ‘Bilirubin and pregnancy’, ‘Iron and pregnancy’ and ‘PPAR and Haem’, selecting consensus conferences, recommendations, meta-analyses, practical recommendations and reviews. A second literature analysis was performed, including notable miscarriages, foetal loss and diabetes mellitus, on 20 December 2019. The three authors studied the publications independently to decipher whether they should be included in the manuscript. OBJECTIVE AND RATIONALE This review aimed to summarise current pieces of knowledge of haem oxygenase location, function and regulation in the placenta, either in healthy pregnancies or those associated with miscarriages and foetal loss, pre-eclampsia, foetal growth restriction and diabetes mellitus. OUTCOMES HO-1 exerts some protective effects on the placentation, probably by a combination of factors, including its interrelation with the PGC-1α/PPAR pathway and the sFlt1/PlGF balance, and through its primary metabolites, notably carbon monoxide and bilirubin. Its protective role has been highlighted in numerous pregnancy conditions, including pre-eclampsia, foetal growth restriction, gestational diabetes mellitus and miscarriages. WIDER IMPLICATIONS HO-1 is a crucial enzyme in physiological and pathological placentation. This protective enzyme is currently considered a potential therapeutic target in various pregnancy diseases.

The Effects of Nicotine on Foetal Loss, Postnatal Growth and Plasma Oestrogen and Progesterone Levels in Rats

Introduction: The present study aims to investigate the effects of nicotine on foetal loss, postnatal growth and corresponding levels of oestrogen and progesterone in pregnant rats. Method: Subcutaneous injection of nicotine tartrate (7.5 mg/kg/day) was administered to groups of pregnant rats; with treatment scheduled from day 1 through day 5, day 5 through day 9 or day 1 through day 9 of pregnancy. On day 10 of pregnancy, laparotomy was performed to count the number of blastocyst implantation sites. During parturition, the number of viable pups was recounted and statistically compared with the controls. One group of rats which received nicotine from day 1 through day 9 of pregnancy was sacrificed on day 16 of pregnancy, and circulating levels of oestrogen and progesterone were measured. Upon delivery, the birth weight of the pups was measured, and their weights were recorded until weaning. Result: There was a significant increase in foetal loss particularly in rats which received nicotine from day 5 through day 9 and from day 1 through day 9 of pregnancy. There was also significantly lower birth weight of pups in all groups; however, this pattern did not continue until weaning. Plasma oestrogen level was significantly elevated with a significant decrease in the plasma progesterone level. Conclusion: Nicotine administration during pregnancy showed an increase in foetal loss with a corresponding increase in oestrogen and decrease in progesterone levels. Although the birth weight of the pups was low, there was catch-up growth in the pups.

P2246Maternal and foetal outcomes of anticoagulation in pregnant women with preconception venous thromboembolism

Background Anticoagulation is essential to prevent recurrent venous thromboembolism (VTE) during pregnancy in women with a history of preconception VTE. However, information on the safety of anticoagulant drugs in this setting is limited. Purpose To investigate the risk of maternal and foetal adverse outcomes associated with anticoagulant exposure during pregnancy. Methods Nationwide cohort of all pregnant women in Denmark with preconception VTE, 2000–2017. We linked individual-level data from nationwide registries on anticoagulant exposure, maternal and foetal outcomes. Results Among 5,099 pregnancies in 3,246 women with preconception VTE (mean age 31 years, 41% nulliparous), 36.4% were exposed to anticoagulants during first trimester (66.4% low-molecular-weight heparin (LMWH), 31.9% VKA, and 1.8% NOAC (Table). No maternal deaths occurred. Maternal outcomes were comparable among LMWH and unexposed women, whereas recurrent VTE and foetal loss was more prevalent in VKA and NOAC exposed women. Foetal risk was lowest in unexposed and LMWH exposed, whereas preterm birth was prevalent in VKA and NOAC exposed. Table 1. Maternal and foetal outcomes in pregnant women with preconception VTE according to first trimester anticoagulant exposure Maternal outcomes No anticoagulants LMWH VKA NOAC Total pregnancies/singleton foetuses, N 3,244/2,722 1231/1,124 591/442 33 /26 Recurrent VTE, % (N) 2.7 (89) 3.3 (41) 6.4 (38) – (<5) Antenatal bleeding, % (N) 2.3 (73) 2.7 (33) 1.5 (9) 0 Preeclampsia, % (N) 3.0 (98) 2.1 (26) 4.4 (26) – (<5) Foetal loss, % (N) 13.4 (436) 6.6 (81) 22.2 (131) 21.2 (7) Foetal outcomes in live singleton births, except stillbirth Stillbirth, % (N) 0.6 (17) 0.6 (7) – (<5) 0 Mean gestational age, days/birthweight, gram 246/3,458 246/3,471 238/3,212 243/3,138 Preterm birth (<37 weeks), % (N) 41.1 (1,111) 38.3 (428) 63.2 (277) 57.7 (15) Very preterm birth (<28 weeks), % (N) 0.9 (24) 1.3 (14) 2.7 (12) 0 Small for gestational age, % (N) 4.2 (109) 4.5 (49) 4.8 (20) – (<5) Mean 5-minute Apgar score, (sd) 9.8 (0.8) 9.8 (0.7) 9.8 (1.0) 9.7 (1.0) Congenital defects 8.4 (226) 9.0 (100) 10.0 (44) – (<5) Counts are supressed in cells with <5 observations to prevent disclosure of potentially identifiable information. Conclusion Our findings are reassuring and in support of the recommendation of LMWH for pregnant women with prior VTE. Few women were exposed to NOAC during pregnancy, and the safety of NOACs cannot be substantiated with the current level of evidence. Acknowledgement/Funding The Obel Family Foundation partly funded this research by an unrestricted grant.

Pregnancy outcomes in systemic lupus erythematosus (SLE) women

Background Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory condition with multi-organ involvement predominantly affecting young women. There are very limited studies in pregnancy in Asian SLE patients and therefore we embarked on this study to identify pregnancy outcomes of Malaysian women with SLE. Materials and methods We performed a retrospective study of pregnancy outcomes in SLE patients in our institution from January 2007 to December 2014. A total of 71 pregnancies from 44 women were analysed. Results The mean age of our cohort was 30.5 ± 3.9 years. The rate of active disease at conception, antiphospholipid syndrome and lupus nephritis were 22.5%, 32.4% and 57.7% respectively. SLE flare occurred in 33 out of 71 pregnancies whereas 19 pregnancies were complicated with preeclampsia. The livebirth rate for our cohort was 78.9%, whilst preterm delivery was 42.9%. On univariate analysis, active disease and flare in pregnancy were both strongly associated with foetal loss and preterm delivery. Lupus nephritis (p = 0.011), SLE flare (p = 0.008) and antiphospholipid syndrome (p = 0.032) significantly increased the risk of preeclampsia. Aspirin and hydroxychloroquine were protective against foetal loss [odds ratio (OR) 0.12] and preeclampsia (OR 0.25), respectively. On multivariate analysis, active disease was a predictor of SLE flare (p = 0.002) and foetal loss (p = 0.018) and SLE flare was the main predictor of preterm delivery (p = 0.006). Conclusions Pregnancies in women with SLE should be planned and aspirin and HCQ use were beneficial in reducing adverse pregnancy outcomes.