Grafton, New Zealand
Grafton, New Zealand

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Rowan J.A.,National Womens Health | Rush E.C.,Auckland University of Technology | Obolonkin V.,University of Auckland | Battin M.,National Womens Health | And 2 more authors.
Diabetes Care | Year: 2011

OBJECTIVE - In women with gestational diabetes mellitus, who were randomized to metformin or insulin treatment, pregnancy outcomes were similar (Metformin in Gestational diabetes [MiG] trial). Metformin crosses the placenta, so it is important to assess potential effects on growth of the children. RESEARCH DESIGN AND METHODS - In Auckland, New Zealand, and Adelaide, Australia, women who had participated in the MiG trial were reviewed when their children were 2 years old. Body composition was measured in 154 and 164 children whose mothers had been randomized to metformin and insulin, respectively. Children were assessed with anthropometry, bioimpedance, and dual energy X-ray absorptiometry (DEXA), using standard methods. RESULTS - The children were similar for baseline maternal characteristics and pregnancy outcomes. In the metformin group, compared with the insulin group, children had larger mid-upper arm circumferences (17.2 ± 1.5 vs. 16.7 ± 1.5 cm; P = 0.002) and subscapular (6.3 ± 1.9 vs. 6.0 ± 1.7 mm; P = 0.02) and biceps skinfolds (6.03 ± 1.9 vs. 5.6 ± 1.7 mm; P = 0.04). Total fat mass and percentage body fat assessed by bioimpedance (n = 221) and DEXA (n = 114) were not different. CONCLUSIONS-Children exposed to metformin had larger measures of subcutaneous fat, but overall body fat was the same as in children whose mothers were treated with insulin alone. Further follow-up is required to examine whether these findings persist into later life and whether children exposed to metformin will develop less visceral fat and be more insulin sensitive. If so, this would have significant implications for the current pandemic of diabetes. © 2011 by the American Diabetes Association.


Farquhar C.,Perinatal and Maternal Mortality Review Committee | Farquhar C.,University of Auckland | Sadler L.,Perinatal and Maternal Mortality Review Committee | Sadler L.,National Womens Health | And 4 more authors.
American Journal of Obstetrics and Gynecology | Year: 2011

OBJECTIVE: We sought to describe a new classification system for contributory factors in, and potential avoidability of, maternal deaths and to determine the contributory factors and potential avoidability among 4 years of maternal deaths in New Zealand. STUDY DESIGN: A new classification system for reporting contributory factors in all maternal deaths was developed from previous tools and applied to all maternal deaths in New Zealand from 2006 through 2009. RESULTS: There were 49 deaths and the maternal mortality ratio was 19.2/100,000 maternities. Contributory factors were identified in 55% of cases. An expert panel identified 35% of maternal deaths as potentially avoidable. In cases where potential avoidability was determined, there were nearly always 2 or 3 domains where contributory factors were identified. CONCLUSION: Almost one third of maternal deaths in New Zealand can be considered to be potentially avoidable. This methodology has the potential to identify areas for improvement in the quality of maternity care. © 2011 Mosby, Inc. All rights reserved.


Rush E.C.,Auckland University of Technology | Bristow S.,Auckland University of Technology | Plank L.D.,University of Auckland | Rowan J.,National Womens Health
European Journal of Clinical Nutrition | Year: 2013

Background/Objectives:Bioimpedance analysis (BIA) is a simple, convenient and widely used tool for the measurement of body composition in population surveys and surveillance. Prediction equations based on BIA applicable to preschool children are available but are based on total body water estimation and have not been developed across multiple ethnic groups. Our aim was to develop a BIA-based equation in a multi-ethnic sample of 2-year old using fat-free mass (FFM) from dual-energy X-ray absorptiometry (DXA) as criterion measure.SUBJECTS/METHODS:Single-frequency hand-to-foot BIA (model BIM4, Impedimed) and whole-body DXA measurements were carried out in 77 (35 boys, 42 girls; 27 European, 20 Polynesian, 30 Asian and other) healthy preschool children (age range 22-38 months). Body mass index s.d. scores were 0.41±1.23 for boys and 0.61±1.09 for girls. The performance of published equations applicable to this age group was assessed. The predicted residual sum of squares method was used to develop and cross-validate a multiple regression equation relating FFM to BIA measures.RESULTS:Published equations performed poorly for estimating FFM in this group of children. The prediction equation developed in all 77 children was: FFM (kg)=0.367 height(cm) 2 /resistance+0.188 weight (kg)+0.077 height (cm)+0.273 sex (male=1, female=0)-2.490, R 2 =0.89, standard error of estimate=0.50 kg. Ethnicity and age did not add significantly to the model.CONCLUSIONS:We have developed an equation that may have application for prediction of FFM in 2-3-year-old children, which does not require determination of hydration factors. Further work should be carried out using DXA scanning to extend the applicable age range. © 2013 Macmillan Publishers Limited All rights reserved.


PubMed | University of Auckland, National Womens Health and Auckland City Hospital
Type: | Journal: The Cochrane database of systematic reviews | Year: 2017

Gestational diabetes mellitus (GDM) is a major public health issue with rates increasing globally. Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short- and long-term complications for the mother and her infant. Treatment options can include oral anti-diabetic pharmacological therapies.To evaluate the effects of oral anti-diabetic pharmacological therapies for treating women with GDM.We searched Cochrane Pregnancy and Childbirths Trials Register (14 May 2016), ClinicalTrials.gov, WHO ICTRP (14 May 2016) and reference lists of retrieved studies.We included published and unpublished randomised controlled trials assessing the effects of oral anti-diabetic pharmacological therapies for treating pregnant women with GDM. We included studies comparing oral anti-diabetic pharmacological therapies with 1) placebo/standard care, 2) another oral anti-diabetic pharmacological therapy, 3) combined oral anti-diabetic pharmacological therapies. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review.Women with pre-existing type 1 or type 2 diabetes were excluded.Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy.We included 11 studies (19 publications) (1487 women and their babies). Eight studies had data that could be included in meta-analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM. The overall risk of bias was unclear due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality. Evidence was downgraded for risk of bias (reporting bias, lack of blinding), inconsistency, indirectness, imprecision and for oral anti-diabetic therapy versus placebo for generalisability. Oral anti-diabetic pharmacological therapies versus placebo/standard careThere was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.81 to 1.90; one study, 375 women, very low-quality evidence), birth by caesarean section (RR 1.03, 95% CI 0.79 to 1.34; one study, 375 women, very low-quality evidence), perineal trauma (RR 0.98, 95% CI 0.06 to 15.62; one study, 375 women, very low-quality evidence) or induction of labour (RR 1.18, 95% CI 0.79 to 1.76; one study, 375 women; very low-quality evidence). No data were reported for development of type 2 diabetes or other pre-specified GRADE maternal outcomes (return to pre-pregnancy weight, postnatal depression). For the infant, there was no evidence of a difference in the risk of being born large-for-gestational age (LGA) between infants whose mothers had been treated with glibenclamide and those in the placebo group (RR 0.89, 95% CI 0.51 to 1.58; one study, 375, low-quality evidence). No data were reported for other infant primary or GRADE outcomes (perinatal mortality, death or serious morbidity composite, neurosensory disability in later childhood, neonatal hypoglycaemia, adiposity, diabetes). Metformin versus glibenclamideThere was no evidence of a difference between metformin- and glibenclamide-treated groups for the risk of hypertensive disorders of pregnancy (RR 0.70, 95% CI 0.38 to 1.30; three studies, 508 women, moderate-quality evidence), birth by caesarean section (average RR 1.20, 95% CI 1.20; 95% CI 0.83 to 1.72, four studies, 554 women, IThere were insufficient data comparing oral anti-diabetic pharmacological therapies with placebo/standard care (lifestyle advice) to inform clinical practice. There was insufficient high-quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti-diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short- and long-term clinical outcomes for this review were inadequately reported or not reported. Current choice of oral anti-diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines.The benefits and potential harms of one oral anti-diabetic pharmacological therapy compared with another, or compared with placebo/standard care remains unclear and requires further research. Future trials should attempt to report on the core outcomes suggested in this review, in particular long-term outcomes for the woman and the infant that have been poorly reported to date, womens experiences and cost benefit.


De Sousa J.,National Womens Health | Upadhyay V.,Starship Hospital | Stone P.,University of Auckland
Fetal Diagnosis and Therapy | Year: 2016

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare intestinal dysmotility condition that also involves a dilated urinary bladder. It was believed to be an autosomal recessive condition, but genetic studies have suggested possibly an autosomal dominant inheritance pattern. Prenatal diagnosis can be challenging, but MRI and amniotic fluid/digestive fluid studies may be complementary investigations to improve diagnostic accuracy. Prognosis of MMIHS is generally poor and treatment is mostly supportive. To date, bowel transplantation remains the only viable treatment to restore bowel motility. Here we present two additional cases to contribute towards the scant literature on this condition. © 2015 S. Karger AG, Basel.


Wise M.R.,University of Auckland | Wise M.R.,National Womens Health | Jordan V.,University of Auckland | Lagas A.,University of Auckland | And 5 more authors.
American Journal of Obstetrics and Gynecology | Year: 2016

Objective To systematically review the literature on the association between obesity and endometrial hyperplasia or cancer in premenopausal women. Data Sources We searched the bibliographic databases MEDLINE, EMBASE, PubMed, and CINAHL (inception to May 5, 2015), and checked reference lists of included studies and systematic reviews. Study Eligibility Criteria Studies of more than 50 women with endometrial pathology diagnosed during premenopause that reported on obesity as a risk factor were eligible. Study Appraisal and Synthesis Methods Study identification and data extraction were independently performed by 2 authors. Where possible, data were pooled in a generic inverse variance forest plot. Heterogeneity was reported using the I2 statistic. Results Nine case-control studies of moderate quality were included. Quantitative analysis of 5 studies showed a dose-response relationship of body mass index and increased risk of endometrial cancer. For studies of women with body mass index of ≥25, the pooled odds ratio was 3.85 (95% confidence interval 2.53-5.84); body mass index of ≥30 was 5.25 (4.00-6.90); and body mass index of ≥40 was 19.79 (11.18-35.03). Conclusion Body mass index is a consistent and leading risk factor for endometrial complex hyperplasia or cancer in premenopausal women. Body mass index should be considered when deciding to assess the endometrium in symptomatic premenopausal women. © 2015 Elsevier Inc. All rights reserved.


Rowan J.A.,National Womens Health | Budden A.,National Womens Health | Ivanova V.,National Womens Health | Hughes R.C.,University of Otago | And 2 more authors.
Diabetic Medicine | Year: 2016

Aims: To examine whether women with an HbA1c of 41-49 mmol/mol (5.9-6.6%) at diagnosis of gestational diabetes are higher risk than women with an HbA1c of < 41 mmol/mol (5.9%) and whether pregnancy outcomes are improved if treated at < 24 weeks' gestation. Methods: This was an observational study of women with gestational diabetes diagnosed by early HbA1c screening or subsequent oral glucose tolerance test at < 34 weeks' gestation who delivered at National Women's Health, Auckland, from July 2012 to June 2014. Data were extracted from the hospital database. Women with HbA1c 41-49 mmol/mol (5.9-6.6%) were divided into those seen < 24 weeks (Early, n = 134) and those seen ≥ 24 weeks (Later, n = 151). Those with HbA1c < 41 mmol/mol (5.9%) were labelled Other GDM (n = 661). Results: The Early and Later groups, compared with Other GDM, had more Polynesian and fewer (non-Indian) Asian women, higher BMI and more required medication (P < 0.001). More were smokers (P = 0.007, 0.02) and more had chronic hypertension (P < 0.001, 0.02). There were higher rates of adverse outcomes in the Later group than the Other GDM group (pre-eclampsia 8.0% vs. 2.4%, P = 0.001, preterm birth 16.6% vs. 8.2%, P = 0.002, neonatal admission 15.5% vs. 9.2%, P = 0.02). Outcomes were similar between the Early group and Other GDM group (pre-eclampsia 1.5% vs. 2.4%, P = 0.5, preterm birth 10.5% vs. 8.2% P = 0.4, neonatal admission 13.6% vs. 9.2%, P = 0.12). Comparing the Early and Later groups, the Early group had less pre-eclampsia, 1.5% vs. 8.0%, adjusted P = 0.03. Other outcomes were not statistically different. Conclusions: An HbA1c of 41-49 mmol/mol (5.9-6.7%) identifies a higher-risk group of women with gestational diabetes. Overall, our data support early treatment of women with an HbA1c ≥ 41 mmol/mol (5.9%). © 2016 Diabetes UK.


West C.R.,Middlemore Hospital | Harding J.E.,University of Auckland | Williams C.E.,University of Melbourne | Nolan M.,Starship Childrens Health | Battin M.R.,National Womens Health
Archives of Disease in Childhood: Fetal and Neonatal Edition | Year: 2011

Objective: To assess the use of two-channel electroencephalographical (EEG) recordings for predicting adverse neurodevelopmental outcome (death or Bayley II mental developmental index/psychomotor developmental index < 70) in extremely preterm infants and to determine the relationship between quantitative continuity measures and a specialist neurophysiologist assessment of the same EEG segment for predicting outcome. Design: Observational study. Setting: The study was conducted in a neonatal intensive care unit. Patients: Preterm infants born <29 weeks' gestation. Interventions: Two-channel EEGs using the reBRM2 monitor (BrainZ Instruments, Auckland, New Zealand) within 48 h of delivery. One-hour segments were analysed, blinded to the clinical outcome, by off-line quantitative analysis of continuity and a review of the raw EEG by a neurophysiologist. Main outcome measures: Developmental assessment at a median of 15 months' corrected age. Results: 76 infants had an EEG within 48 h of delivery and a developmental assessment. The analysed segment of the EEG was obtained at 24 (3-48) h of age (median (range)). The neurophysiologist's assessment was a better predictor of adverse outcome than the continuity measures (positive predictive value 95% CI 75 (54% to 96%) vs 41 (22% to 60) at 25-μV threshold, negative predictive value 88 (80% to 96%) vs 84 (74% to 94%) and positive likelihood ratio 9.0 (3.2 to 24.6) vs 2.0 (1.2 to 3.6)). All the infants with definite seizures identified by the neurophysiologist had poor outcomes. Conclusions: Modified cot-side EEG has potential to assist with identification of extremely preterm infants at risk for adverse neurodevelopmental outcomes. However, analysis by a neurophysiologist performed better than the currently available continuity analyses.


Priest P.,University of Otago | Sadler L.,National Womens Health | Sykes P.,University of Otago | Marshall R.,University of Auckland | And 2 more authors.
Cancer Causes and Control | Year: 2010

Objective The aim of this study is to assess whether ethnic inequalities in cervical cancer mortality are due to differences in survival independent of stage and age at diagnosis, and to assess the contribution of screening to stage at diagnosis. Methods Demographic data and cervical screening history were collected for 402 women with histologically proven primary invasive cervical cancer, diagnosed in New Zealand between 1 January 2000 and 30 September 2002. Date of death was available for women who died up to 30 September 2004. Results A Cox proportional hazard model showed that, after adjusting for age, the Maori mortality rate was 1.80 times (95% CI 1.07-3.04) that of non-Mãori. This reduced to 1.25 (95% CI 0.74-2.11) when stage at diagnosis was also adjusted for. Among determinants of late stage at diagnosis, older age and being Maori significantly increased the risk, while screening was protective. Conclusions These results indicate that later stage at diagnosis is the main determinant of Maori women's higher mortality from cervical cancer. Improving cervical screening among Maori women would reduce stage at diagnosis and therefore ethnic inequalities in mortality.


Ayyavoo A.,University of Auckland | Derraik J.G.B.,University of Auckland | Hofman P.L.,University of Auckland | Mathai S.,University of Auckland | And 4 more authors.
PLoS ONE | Year: 2013

Background:There are no data on the metabolic consequences of post-term birth (≥42 weeks gestation). We hypothesized that post-term birth would adversely affect insulin sensitivity, as well as other metabolic parameters and body composition in childhood.Methods:77 healthy pre-pubertal children, born appropriate-for-gestational-age were studied in Auckland, New Zealand: 36 born post-term (18 boys) and 41 (27 boys) born at term (38-40 weeks gestation). Primary outcome was insulin sensitivity measured using intravenous glucose tolerance tests and Bergman's minimal model. Other assessments included fasting hormone concentrations and lipid profiles, body composition from whole-body dual-energy X-ray absorptiometry, 24-hour ambulatory blood pressure monitoring, and inflammatory markers.Results:Insulin sensitivity was 34% lower in post-term than in term children (7.7 vs. 11.6 x10-4·min-1·(mU/l); p<0.0001). There was a compensatory increase in acute insulin response among post-term children (418 vs 304 mU/l; p=0.037), who also displayed lower glucose effectiveness than those born at term (2.25 vs 3.11 x10-2·min-1; p=0.047). Post-term children not only had more body fat (p=0.014) and less fat-free mass (p=0.014), but also had increased central adiposity with more truncal fat (p=0.017) and greater android to gynoid fat ratio (p=0.007) compared to term controls. Further, post-term children displayed other markers of the metabolic syndrome: lower normal nocturnal systolic blood pressure dipping (p=0.027), lower adiponectin concentrations (p=0.005), as well as higher leptin (p=0.008) and uric acid (p=0.033) concentrations. Post-term boys (but not girls) also displayed a less favourable lipid profile, with higher total cholesterol (p=0.018) and LDL-C (p=0.006) concentrations, and total cholesterol to HDL-C ratio (p=0.048).Conclusions:Post-term children have reduced insulin sensitivity and display a number of early markers of the metabolic syndrome. These findings could have important implications for the management of prolonged pregnancies. Future studies need to examine potential impacts later in life, as well as possible underlying mechanisms. © 2013 Ayyavoo et al.

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