Maternal and perinatal outcomes of pregnancies in women with cystic fibrosis – A single centre case-control study

Obstetric and neonatal outcomes among pregnant patients with cystic fibrosis

OBJECTIVE

The pregnancy, delivery, and neonatal outcomes of pregnancies complicated by cystic fibrosis (CF) have yet to be evaluated in a prolonged, population-based study. We sought to evaluate the obstetric and neonatal outcomes in pregnant patients with CF using a national population database.

STUDY DESIGN

Retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). All women who delivered or had a maternal death in the US (2004-2014) were included in the study. Pregnancy, delivery, and neonatal outcomes were compared between women with an ICD-9 diagnosis of cystic fibrosis to those without.

RESULTS

Overall, 9 096 159 women met the inclusion criteria. Of these, 629 women (6.9/100000) had CF. Women with CF were more likely to be younger and have pregestational diabetes mellitus compared to those without. CF in pregnancy was associated with an increased risk of developing gestational diabetes mellitus [aOR 3.20 (95 %CI 2.48-4.15), p = 0.0001], placenta previa [aOR 2.74 (95 %CI 1.30-5.79), p = 0.008], preterm delivery [aOR 2.17 (95 %CI 1.71-2.77), p = 0.0001], operative vaginal delivery [aOR 1.59 (95 %CI 1.17-2.16), p = 0.003], and death [aOR 86.41 (95 %CI 30.91-241.58), p = 0.0001], and a decreased likelihood of having a spontaneous vaginal delivery [aOR 0.80 (95 %CI 0.66-0.97), p = 0.02]. Patients with CF were more likely to experience deep venous thrombosis [aOR 7.64 (95 %CI 1.90-30.72), p = 0.004] and disseminated intravascular coagulation [aOR 3.68 (95 %CI 1.37-9.87), p = 0.01] compared to those without. The risk of delivering a fetus with congenital anomalies was similar between groups.

CONCLUSION

Pregnant patients with CF have an increased risk of developing adverse maternal and delivery outcomes. As such, these patients should receive vigilant surveillance during pregnancy.

Effects of modulator therapies on endocrine complications in adults with cystic fibrosis: a narrative review

Cystic fibrosis is a monogenic disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein, which transports chloride ions in secretory organs. Modulator therapies are small molecules that correct CFTR dysfunction and can lead to a wide range of benefits for both pulmonary and extrapulmonary complications of cystic fibrosis. With advancements in airway, antimicrobial and nutritional therapies and now introduction of modulator therapies, most people living with cystic fibrosis in Australia are now adults. For adults with cystic fibrosis, endocrine manifestations such as cystic fibrosis-related diabetes, metabolic bone disease, and reproductive health are becoming increasingly important, and emerging evidence on the endocrine effects of CFTR modulator therapies is promising and is shifting paradigms in our understanding and management of these conditions. The management of cystic fibrosis-related diabetes will likely need to pivot for high responders to modulator therapy with dietary adaptions and potential use of medications traditionally reserved for adults with type 2 diabetes, but evidence to support changing clinical care needs is currently lacking. Increased attention to diabetes-related complications screening will also be required. Increased exercise capacity due to improved lung function, nutrition and potentially direct modulator effect may have a positive impact on cystic fibrosis-related bone disease, but supporting evidence to date is limited. Fertility can improve in women with cystic fibrosis taking modulator therapy. This has important implications for pregnancy and lactation, but evidence is lacking to guide pre-conception and antenatal management. Provision of multidisciplinary clinical care remains ever-important to ensure the emergence of endocrine and metabolic complications are optimised in adults with cystic fibrosis.

Pregnancy in women with cystic fibrosis and diabetes: An audit of outcomes at two tertiary obstetric hospitals in Australia in the pre-cystic fibrosis transmembrane conductance regulator modulator era

Background

Pregnancy in women with cystic fibrosis (CF) is becoming more common. Long-term metabolic issues such as diabetes are also becoming more common and have potentially important impacts on pregnancy outcomes. This study aimed to assess the impact of diabetes on pregnancy outcomes for women with CF.

Methods

We undertook a retrospective chart audit of pregnancies to women with CF at the two tertiary obstetric hospitals in Southeast Queensland associated with CF and transplant management clinics between 2006 and 2016.

Results

A total of 38 pregnancies among 26 women were identified. Four women (five pregnancies) had cystic fibrosis-related diabetes (CFRD) diagnosed prior to pregnancy, and 12 women (15 pregnancies) developed gestational diabetes (GDM) complicating pregnancy. CFRD and GDM were associated with higher rates of delivery complications, prematurity, and the need for neonatal intensive care unit admission.

Conclusion

Diabetes is common during pregnancy in women with CF and impacts pregnancy outcomes.

[Parenthood challenged by cystic fibrosis. Experience of affected parents]

INTRODUCTION

Medical progress affords patients with cystic fibrosis (CF) the opportunity to become parents.

OBJECTIVE

To assess the psychological issues of parenthood in persons with cystic fibrosis.

MATERIAL AND METHODS

Semi-structured interviews on parenthood, conducted by a psychologist with CF parents treated at the Cystic Fibrosis Center and the Transplantation Center of Foch hospital (Suresnes, France).

RESULTS

Twenty-one (21) fathers and 22 mothers participated ; 84 % had become parents through pregnancy, 14% via adoption and one woman by means of surrogacy; 73% of the women and 67% of the men had done so prior to lung transplantation, while 25% had achieved parenthood without or against medical advice. As parents, they suffered from a lack of familial and medical support for their parental projects and a lack of recognition of their reproductive difficulties.

CONCLUSION

While the desire for a child may be initially repressed by potentially life-threatening risks, a loving couple with a satisfying sexual life may in many instances surmount the repression and express the desire, which is not only the desire for a potentially life-bearing body, but also the desire to start a family.

Gestational and pregestational diabetes in pregnant women with cystic fibrosis

As cystic fibrosis transmembrane regulator (CFTR) modulator therapies offer greater longevity and improved health quality, women living with cystic fibrosis (CF) are increasingly pursuing pregnancy. Maternal risks for pregnant women with CF largely depend on a woman's baseline pulmonary and pancreatic function, and the majority of CF pregnancies will successfully end in live births. Diabetes, either gestational or pre-existing cystic fibrosis-related diabetes (CFRD), is highly prevalent in women with CF, affecting 18 to 62% of pregnancies in recent CF center reports. In addition to the rising incidence of CFRD with age, gestational diabetes is also more common in women with CF due to lower insulin secretion, higher insulin resistance, and increased hepatic glucose production as compared to pregnant women without CF. Diabetes occurring during pregnancy has important implications for maternal and fetal health. It is well established in women without CF that glycemic control is directly associated with risks of fetal malformation, neonatal-perinatal mortality, cesarean delivery and need for neonatal intensive care. Small studies in women with CF suggest that pregnancies affected by diabetes have an increased risk of preterm delivery, lower gestational age, and lower fetal birth weight compared to those without diabetes. Women with CF preparing for pregnancy should be counseled on the risks of diabetes and should undergo routine screening for CFRD with oral glucose tolerance testing (OGTT) if not already completed in the past six months. Glycemic control in those with pre-gestational CFRD should be optimized prior to conception. Insulin is preferred for the management of diabetes in pregnant women with CF via multiple daily injections or insulin pump therapy, and continuous glucose monitors (CGM) can be useful in mitigating hypoglycemia risks. Women with CF face many unique challenges impacting diabetes care during pregnancy and would benefit from support by a multidisciplinary care team, including nutrition and endocrinology, to ensure healthy pregnancies.

Cystic Fibrosis-Related Diabetes Mellitus and Pregnancy: A Retrospective Study

INTRODUCTION

Cystic fibrosis-related diabetes mellitus (CFRDM) is becoming a more common issue in pregnancy care as the life expectancy of females living with cystic fibrosis has improved, with an increasing number of pregnancies in this population. Despite the Republic of Ireland having the highest incidence of cystic fibrosis globally, there is limited Irish data on pregnancy outcomes for those with CFRDM. This study aimed to retrospectively review maternal and foetal outcomes of pregnancies affected by maternal CFRDM.

METHODS

The patient records of all women with CFRDM who attended the National Maternity Hospital Dublin for obstetric care between 2015 and 2019 were retrospectively reviewed.

RESULTS

A search of patient records identified 15 pregnancies in 12 women with CFRDM during the study period. CFRDM was diagnosed pre-conception in ten of the 15 pregnancies. Median neonatal weight at birth was lower in women with CFRDM diagnosed pre-conception compared to women diagnosed during pregnancy (2.8 vs. 3.02 kg). The median weight gain in women with CFRDM diagnosed pre-conception was 10.9 kg compared to 11.9 kg for those diagnosed during pregnancy. The majority of women (62.5%) with CFRDM diagnosed pre-conception delivered via caesarean section. Admission for CF exacerbations during pregnancy in women with CFRDM diagnosed pre-conception was very common (87.5%) compared with 75% of those diagnosed during their pregnancy.

CONCLUSION

Women diagnosed with CFRDM were likely to require caesarean section, to be treated with insulin, and to be frequently admitted to hospital for CF exacerbations. Our review highlights the importance of good glucose control, stable cystic fibrosis before pregnancy and a multidisciplinary team approach.

Emerging non-pulmonary complications for adults with cystic fibrosis

Improved treatments of cystic fibrosis (CF) related lung disease have resulted in increased longevity, but also increasing prevalence and severity of extrapulmonary manifestations of CF, treatment related complications, age-related conditions and psychosocial effects of longstanding chronic disease. Likewise, the recognition of mild CF phenotypes has changed the landscape of CF disease. This review outlines our current understanding of the common extrapulmonary complications of CF, as well as the changing landscape and future directions of the extrapulmonary complications experienced by patients with CF.

Pregnancy rates and outcomes in women with cystic fibrosis in the UK: comparisons with the general population before and after the introduction of disease-modifying treatment, 2003-17

OBJECTIVE

To compare pregnancy rates and outcomes for women with cystic fibrosis in the UK with those of the general population and assess the effect of the introduction of disease-modifying treatment.

DESIGN

A population-based longitudinal study, 2003-17.

SETTING

United Kingdom.

POPULATION

Women aged 15-44 years in the UK cystic fibrosis (CF) Registry compared with women in England and Wales.

METHODS

We calculated pregnancy and live-birth rates for the CF population and the general population of England and Wales. For women with CF we compared pregnancy rates before and after ivacaftor was introduced in 2013. We further used CF registry data to assess pregnancy outcomes for mothers with CF, and to assess the relationship between maternal pre-pregnancy lung function and nutritional status and child gestational age.

MAIN OUTCOME MEASURES

Pregnancy and live-birth rates and child gestational age.

RESULTS

Of 3831 women with CF, 661 reported 818 pregnancies. Compared with the general population, the pregnancy rate was 3.3 times lower in the CF population (23.5 versus 77.7 per 1000 woman-years); the live-birth rate was 3.5 times lower (17.4 versus 61.4 per 1000 woman-years) with 70% of pregnancies in CF women resulting in live births; termination of pregnancy rates were also lower (9% versus 22%). Pregnancy rates increased post-ivacaftor for eligible women with CF, from 29.7 to 45.7 per 1000 woman-years. There was no association between pre-pregnancy lung function/nutrition status and gestational age.

CONCLUSIONS

Pregnancy rates in women with CF are about one-third of the rates in the general population with favourable outcomes, and increased for eligible women post-ivacaftor.

TWEETABLE ABSTRACT

Pregnancy rates in women with CF are about a third of the rate in England and Wales with 70% live births. Ivacaftor increases the rate.

Perinatal outcomes in women with cystic fibrosis: Data from the Italian Cystic Fibrosis Registry

INTRODUCTION

Data from the Italian Cystic Fibrosis Registry concerning pregnancies in the period 2010-2015 were used to investigate the association between the preconception clinical status and perinatal outcomes of women with cystic fibrosis (CF).

MATERIAL AND METHODS

The assessed clinical variables were genotype, age at the time of conception, body mass index (BMI) and the percentage of predicted forced expiratory volume in the first second (ppFEV₁ ). The analyzed outcomes were gestational age, birthweight and the frequency of cesarean deliveries. A generalized linear mixed model (GLIMMIX) was used to evaluate the association between type of delivery and age at the time of becoming pregnant, BMI, ppFEV₁ and gestational age. Robust multivariable regression was used to evaluate the relation between gestational age and age at the time of becoming pregnant, BMI and ppFEV₁ . Multivariable linear regression was performed to verify association between birthweight and BMI, and ppFEV₁ .

RESULTS

Complete information concerning mother and child was available for 56 completed pregnancies. Median age at the time of conception was 30.8 years (range: 18.7-42.3); median BMI was 21.5 kg/m² (range: 16.5-26.8); and median ppFEV₁ was 73.9 (range: 30-128). In all, 31 women (55.36%) had a genotype consisting of two CF-causing variants. Eight were homozygous for the F508del mutation (14.28% of the total). The median duration of pregnancy was 37 weeks (range: 31-41) and the frequency of prematurity (<37 weeks of gestational age) was 28.30%. Median birthweight was 2910 g (range: 1300-3650). The overall frequency of cesarean sections was 63.64%. A low preconception ppFEV₁ was associated with prematurity (p = 0.014), and birthweight was positively related to ppFEV₁ (p = 0.04). There was no association between the clinical variables or gestational age and the type of delivery.

CONCLUSIONS

Maternal preconceptional respiratory function correlates with the duration of pregnancy and the birthweight of newborns. Cesarean deliveries are also frequent among young women with CF with normal respiratory function.

Sexual and reproductive health in cystic fibrosis

PURPOSE OF REVIEW

With improving life expectancy and quality of life, sexual and reproductive health (SRH) has become an increasingly important aspect of patient-centered cystic fibrosis care. This review aims to describe advances in cystic fibrosis-related SRH and highlight optimal practices.

RECENT FINDINGS

Recent publications suggest that people with cystic fibrosis follow a similar trajectory of sexual development and activity as their noncystic fibrosis peers, although contraception use is lower. Although fertility is reduced in patients with cystic fibrosis, improved survival and assisted reproductive technologies have led to an increasing pursuit and incidence of pregnancy. Cystic fibrosis transmembrane regulator modulators that correct the underlying cystic fibrosis defect might improve fertility and thus far appear safe in pregnancy, though data are limited.Despite medical knowledge of SRH in cystic fibrosis, patients continue to report they lack sufficient education about these aspects of their healthcare, and cystic fibrosis multidisciplinary teams are ill prepared to counsel their patients.

SUMMARY

Understanding of the effects of cystic fibrosis on SRH continues to improve, although many questions remain regarding optimal care from the choice of contraception to the safety of cystic fibrosis-specific medications in pregnancy. Further development of cystic fibrosis-informed interdisciplinary specialist networks and a wider framework of practice would both enhance health outcomes and better support patients.

Baseline Cystic fibrosis disease severity has an adverse impact on pregnancy and infant outcomes, but does not impact disease progression

BACKGROUND

With increasing longevity and quality of life in adults with Cystic fibrosis (CF), growing maternity rates are reported. Women with severe CF are becoming pregnant, with unpredictable maternal and fetal outcomes.

AIM

To determine how baseline disease severity, pancreatic insufficiency (PI) and Pseudomonas aeruginosa (PA) infection affect fertility, the pregnancy course, delivery, neonatal outcome, and subsequent disease progression.

METHODS

A multicenter-retrospective cohort study. Data on patients that had been pregnant between 1986-2018 was collected from ten CF centers worldwide. Disease severity [mild or moderate-severe (mod-sev)] was defined according to forced expiratory volume % predicted in 1 second (FEV₁) and body mass index (BMI). Three time periods were compared, 12 months prior to conception, the pregnancy itself and the 12 months thereafter.

RESULTS

Data was available on 171 pregnancies in 128 patients aged 18-45 years; 55.1% with mod-sev disease, 43.1% with PI and 40.3% with PA. Women with mod-sev disease had more CF-related complications during and after pregnancy and delivered more preterm newborns. However, FEV₁ and BMI decline were no different between the mild and mod-sev groups. A more rapid decline in FEV₁ was observed during pregnancy in PI and PA infected patients, though stabilizing thereafter. PI was associated with increased risk for small for gestational age infants.

CONCLUSION

Baseline disease severity, PA infection and PI have an adverse impact on infant outcomes, but do not impact significantly on disease progression during and after pregnancy. Consequently, pregnancies in severe CF patients can have a good prognosis.

How do cystic fibrosis patients experience parenthood? A systematic review

Improved treatments for cystic fibrosis allow more patients to become parents. This article presents a systematic review of literature on cystic fibrosis patients’ experience of parenthood. Five databases (Cairn, Cochrane Library, PsycINFO, PubMed and ScienceDirect) produced 2335 documents that were screened. In total, 13 documents were retained and assessed with validated criteria. Five themes related to cystic fibrosis parenthood were discovered: population presentation, health and treatment adherence, adjustments, role of professionals and pressured temporality. Parenthood requires an important reorganisation of daily life in order to remain capable of childcare. Regardless of negative health impacts, cystic fibrosis parents have a positive outlook on parenthood.

[Cystic fibrosis and pregnancy: Outcome, prognostic factors and obstetrical management]

As a result of improvements in life expectancy and therapies, increasing numbers of patients with cystic fibrosis become pregnant. The first studies were pessimistic and report adverse outcomes on the fetus and the mother. In the recent publications, long-term outcome for women with cystic fibrosis does not appear to be negatively impacted by pregnancy. Furthermore, the number of women successfully completing pregnancy continues to rise. The aim of this review is to assess the outcome of pregnancy in women with cystic fibrosis and the impact of pregnancy on the disease. It is hoped it will improve the counseling for pregnant women with cystic fibrosis and their obstetrical management.

Fertility of women with cystic fibrosis: a French survey

RESEARCH QUESTION

Although the impact of cystic fibrosis on male fertility is well known, very few studies have investigated its effect on female fertility. This study aimed to evaluate the fertility status of women with cystic fibrosis.

DESIGN

A questionnaire was sent to 220 women with cystic fibrosis. The questions concerned their desire to become a parent, achievement or not of a pregnancy, the time to become pregnant, the means of achieving pregnancy (spontaneously or with medical assistance) and the outcome of the pregnancy. Ninety-eight patients responded to the questionnaire.

RESULTS

Of the 46 women who sought pregnancy, 25 (54%) had at least one live birth without treatment, while 11 (24%) required infertility treatment to obtain a live birth and 10 (22%) had no delivery. The mean time-to-pregnancy was 12 months (1-180). The reasons for preferring not to become pregnant were mainly fear of the interaction between cystic fibrosis and pregnancy and of the transmission of cystic fibrosis to children.

CONCLUSIONS

Fertility seems to be slightly impaired in women with cystic fibrosis, because 37% of them failed to become pregnant without medical assistance. Because the outcome of pregnancies appears normal, patients should be informed about the possibility of becoming mothers and be made aware of the risk of unwanted pregnancies.

Obstetric care in women with genetic disorders

The management of pregnant women who are themselves affected with genetic diseases is an increasingly relevant and important issue. Improvements in early diagnosis and management of genetic disease, as well as advances in assisted reproductive technology have impacted pregnancy rates in a cohort of women who may not have otherwise been able to conceive. A multidisciplinary approach is key to the management of pregnant women with complex health conditions, including genetic diseases. Pertinent issues should be addressed in the preconception, antepartum, intrapartum and postpartum periods to optimize maternal and fetal health. Additionally, counseling regarding risk of inheritance in offspring and options for prenatal diagnosis should be reviewed if available. This reviews aims to help provide background and insight into the management strategies for various commonly encountered and complex genetic conditions in the setting of pregnancy.

Fertility Awareness Counseling for Adolescent Girls; Guiding Conception: The Right Time, Right Weight, and Right Way

STUDY OBJECTIVE

To provide a detailed summary of fertility awareness counseling pearls for healthy teens and those with fertility-relevant comorbidities, and to assist providers in offering such counseling to adolescents and young adult women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Comprehensive literature review of English-language studies relating to fertility in pediatric and adolescent female patients (ages 13-21 years), and evidence-based dialogue guide.

RESULTS

The literature indicates that although adolescents are interested in discussing sexuality and reproduction, this is commonly overlooked during the standard office medical visit. As a result, adolescents often turn to less reliable sources and hold a variety of reproductive misconceptions and a sense of lack of control over future fertility. We found no studies that examined the routine provision of fertility awareness counseling with healthy adolescents. There are a multitude of specific gynecologic and medical conditions that have ramifications for fertility. We detail these comprehensively, and provide a dialogue guide to assist with fertility awareness counseling for the female adolescent, containing specific information and indications for referral.

CONCLUSION

Providers caring for adolescent girls have the opportunity to enhance fertility awareness as part of a larger reproductive health conversation that adolescents desire, and from which they might benefit. Identifying potential future fertility issues, understanding age-related fertility decline, and aiding in health optimization before future conception might empower the adolescent to make informed reproductive decisions. We provide an algorithm to use with adolescents to discuss the "right time, right weight, right way" to pursue childbearing.