Objective  To develop a practical evidence based list of clinical risk factors that can be assessed by a clinician at ≤16 weeks’ gestation to estimate a woman’s risk of pre-eclampsia. Design  Systematic review and meta-analysis of cohort studies. Data sources  PubMed and Embase databases, 2000-15. Eligibility criteria for selecting studies  Cohort studies with ≥1000 participants that evaluated the risk of pre-eclampsia in relation to a common and generally accepted clinical risk factor assessed at ≤16 weeks’ gestation. Data extraction  Two independent reviewers extracted data from included studies. A pooled event rate and pooled relative risk for pre-eclampsia were calculated for each of 14 risk factors. Results  There were 25 356 688 pregnancies among 92 studies. The pooled relative risk for each risk factor significantly exceeded 1.0, except for prior intrauterine growth restriction. Women with antiphospholipid antibody syndrome had the highest pooled rate of pre-eclampsia (17.3%, 95% confidence interval 6.8% to 31.4%). Those with prior pre-eclampsia had the greatest pooled relative risk (8.4, 7.1 to 9.9). Chronic hypertension ranked second, both in terms of its pooled rate (16.0%, 12.6% to 19.7%) and pooled relative risk (5.1, 4.0 to 6.5) of pre-eclampsia. Pregestational diabetes (pooled rate 11.0%, 8.4% to 13.8%; pooled relative risk 3.7, 3.1 to 4.3), prepregnancy body mass index (BMI) >30 (7.1%, 6.1% to 8.2%; 2.8, 2.6 to 3.1), and use of assisted reproductive technology (6.2%, 4.7% to 7.9%; 1.8, 1.6 to 2.1) were other prominent risk factors. Conclusions  There are several practical clinical risk factors that, either alone or in combination, might identify women in early pregnancy who are at “high risk” of pre-eclampsia. These data can inform the generation of a clinical prediction model for pre-eclampsia and the use of aspirin prophylaxis in pregnancy.

https://www.bmj.com/content/bmj/353/bmj.i1753.full.pdf

Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies

Background Parenteral nutrition (PN) is a high-alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence-based policies, procedures, and practices. This document provides evidence-based guidance for clinical practices involving PN prescribing, order review, and preparation. Method A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium-phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade ("premixed") multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2-in-1 compared with 3-in-1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3-in-1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na- or K-) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non-nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient-specific volumes are safe? (12) What beyond-use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?

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A.S.P.E.N. Clinical Guidelines Parenteral Nutrition Ordering, Order Review, Compounding, Labeling, and Dispensing

Improved conditions of care for premature infants have led to markedly increased survival rates over the last few decades, particularly in very low and extremely low birth weight infants Nutritional measures play a central role in the long-term outcome, health and quality of life of these premature infants In this publication, leading experts from all 5 continents present the most recent evidence and critical analyses of nutrient requirements and the practice of nutritional care (with the focus on very low birth weight infants) to provide guidance for clinical application After the introductory chapters, covering nutritional needs and research evidence in a more general manner, topics such as amino acids and proteins, lipids, microminerals and vitamins, parenteral and enteral nutrition as well as approaches to various disease conditions are addressed Due to its focus on critical appraisals and recommendations, this book is of interest not only for the researcher who wants to keep up to date, but also for the clinician faced with premature infants in his practice

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Nutritional care of preterm infants: scientific basis and practical guidelines.

ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Calcium, phosphorus and magnesium

Metabolic Bone Disease (MBD) of prematurity is a multifactorial disorder commonly observed in very low birth weight (VLBW, <1,500 g) newborns, with a greater incidence in those extremely low birth weight (ELBW, <1,000 g). MBD is characterized by biochemical and radiological findings related to bone demineralization. Several antenatal and postnatal risk factors have been associated to MBD of prematurity, although the main pathogenetic mechanism is represented by the reduced placental transfer of calcium and phosphate related to preterm birth. The diagnosis of MBD of prematurity requires the assessment of several biochemical markers, radiological, and ultrasonographic findings. However, the best approach is the prevention of the symptomatic disease, based on the screening of subjects exposed to the risks of developing MBD. Regarding the subjects who need to be screened, there is a substantial agreement on the potential risk factors for MBD. On the contrary, different recommendations exist on the diagnosis, management and treatment of this disorder of bone metabolism. This review was aimed at: (1) identifying the subjects at risk for MBD of prematurity; (2) indicating the biochemical findings to take in consideration for the prevention of MBD of prematurity; (3) suggesting practical recommendations on nutritional intake and supplementation in these subjects. We searched for papers which report the current recommendations for biochemical assessment of MBD of prematurity and for its prevention and treatment. The majority of the authors suggest that MBD of prematurity is a disease which tends to normalize overtime, thus it is not mandatory to mimic the rate of mineral fetal accretion through parenteral or enteral supplementation. The optimization of total parenteral nutrition (TPN) and the early achievement of a full enteral feeding are important goals for the prevention and management of MBD of prematurity.

/pdf/metabolic-bone-disease-of-prematurity-diagnosis-and-3wli0nhns7.pdf

Metabolic Bone Disease of Prematurity: Diagnosis and Management

Background and Aim:Very premature newborns have an increased risk of low bone mass and metabolic bone disease. Most longitudinal studies report a significant decline in bone strength in the first weeks after birth. The aim of the study was to evaluate whether higher early calcium (Ca) and ph

Early high calcium and phosphorus intake by parenteral nutrition prevents short-term bone strength decline in preterm infants.

Background/Aims: Familial Renal Glucosuria (FRG) is characterized by the presence of persistent isolated glucosuria in the absence of hyperglycemia. Mutations in SLC5A2, the gene coding for the sodium-glucose co-transporter 2 (SGLT2), are responsible for FRG. Phenotype/genotype correlations in FRG have mostly relied on the quantification of Urinary Glucose Excretion (UGE), which is dependent on both the filtered glucose load and the renal glucose reabsorptive capacity. In the current work, the renal threshold for glucose excretion (RTG) was determined in an FRG cohort, with the purpose of characterizing the impact of SGLT2 mutations on renal glucose transport. Methods: From January to December of 2013, eight FRG individuals with identified SLC5A2 mutations were enrolled. Patients were given a Mixed-Meal Tolerance Test during which blood glucose and UGE were measured over a 4 h period and the data was used to calculate RTG, according to a recently validated protocol. Results: In patients with homozygous mutations, RTG values were very low, with a mean (SD) of 0.95 (1.17) mmol/l, compared to commonly reported values of approximately 10-11.1 mmol/l in healthy subjects. In subjects with heterozygous mutations, mean (SD) RTG values were 4.91 (1.23) mmol/l, which are approximately one-half of the values in subjects without mutations. Conclusions: In FRG, mutations in SLC5A2 lead to reductions in RTG and increases in UGE. Because determination of RTG is not influenced by the filtered glucose load, the calculated RTG values provide a more refined measure of the impact of mutations on renal glucose transport than can be obtained from UGE alone.

Determination of the Renal Threshold for Glucose Excretion in Familial Renal Glucosuria

Introduction: To analyze the cesarean section rate evolution in a tertiary hospital and the main indications for cesarean section. Material and Methods: A retrospective study was conducted at a major academic hospital and included 5 751 women who had a cesarean section from 2005 to 2011. The rates of overall, primary and repeat cesarean sections were analyzed. A linear regression and adjusted R-square were used to access the relative contribution of each indication to the variation in primary cesarean section. Results: During the 7-year period of the study the cesarean section rate decreased from 30.9% to 27.6%. This was due to a decrease in primary cesarean section (21.9% to 18.2%), although an increase in repeat cesarean section was observed (9.0% to 9.4%). Among the indications for primary cesarean section, maternal-fetal indications and malpresentation were the ones that decreased the most with adjusted R-square of 0.70 and 0.55, respectively. Discussion: The collected data identified that the decrease in the cesarean section rate at the hospital resulted from a decrease in primary cesarean section deliveries, especially the ones performed for maternal-fetal indications and malpresentation. Conclusion: The decrease in primary cesarean section rate may be attributed to several changes in medical policies in the Department, such as the implementation of an external fetal version program, the induction of labor only after the 41st week of gestation in low-risk pregnancies and the trial for vaginal birth in maternal-fetal disease. Nevertheless subjective indications such as labor arrest disorders and nonreassuring fetal heart rate are still major contributors for primary cesarean section rate.

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Indications for Cesarean Deliveries during a 7-Year Period in a Tertiary Hospital

Route of delivery following successful external cephalic version

Objectivo: Estabelecer valores de referencia da robustez ossea nos primeiros dias de vida, em recem-nascidos de termo e pre-termo adequados para a idade de gestacao nascidos em Portugal. Metodos: Foi medida a velocidade do som (VdS) (m/s) por ultrassonografia quantitativa, numa amostra sistematica de recem-nascidos adequados para a idade de gestacao, de termo e pre-termo, respectivamente nos primeiros dois e cinco dias apos o nascimento. Foi avaliada a homogeneidade de valores entre generos e entre grupos de idade de gestacao. Resultados: A amostra constou de 158 recem-nascidos, 34 de termo e 124 pre-termo (idade de gestacao entre 26 a 41 semanas), com peso de nascimento de 595 g a 4195 g, 84 do sexo masculino (53,2%) e 20 gemeos (10,8%). A media da VdS aumenta significativamente com a idade de gestacao. Sao providenciados valores de referencia da VdS para os percentis 10, 25, 50, 75 e 90, para grupos de idade de gestacao, sem distincao para o genero. Conclusao: Sao disponibilizados valores de referencia de VdS nos primeiros dias de vida, de recem-nascidos adequados para a idade de gestacao, de termo e pre-termo, nascidos em Portugal. Estes valores reflectem a robustez ossea intrauterina e servem de referencia basal para estudos evolutivos realizados em Portugal.

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Ana Costa

Papers

Early high calcium and phosphorus intake by parenteral nutrition prevents short-term bone strength decline in preterm infants.

Determination of the Renal Threshold for Glucose Excretion in Familial Renal Glucosuria

Indications for Cesarean Deliveries during a 7-Year Period in a Tertiary Hospital

Route of delivery following successful external cephalic version

Reference values for bone strength assessed by quantitative ultrasound early after birth in term and preterm neonates