Short term outcomes following breast cancer surgery in pregnant women

ObjectiveBreast cancer is the most common malignancy in pregnancy with an estimated prevalence of 1 per 3000 pregnancies. The National Comprehensive Cancer Network (NCCN) guidelines advocate for surgical management in all trimesters for pregnant women with breast cancer but few studies have examined the impact breast cancer surgery has on outcomes in pregnant women. We aimed to identify differences in short term outcomes after breast cancer surgery between age-matched pregnant and non-pregnant women.MethodsThis was a retrospective, cross-sectional study utilizing the Health Care Utilization Project-Nationwide Impact Sample (HCUP-NIS) database from 1999 to 2006. All pregnant women with breast cancer undergoing lumpectomy or mastectomy were compared to age-matched non-pregnant women. Demographics, in-hospital mortality, length of stay, hospital cost, and discharge disposition were reviewed. Statistical analysis was performed with chi-square, Student's t-test, and ANOVA with p < 0.05 deemed significant.ResultsOver an 8 year period, 185 pregnant women (mean age 35 years) and 47,985 non-pregnant age-restricted women (mean age 45 years) who underwent breast cancer surgery were identified. There was no significant difference between in-hospital mortality, length of stay, cost of hospitalization, or discharge disposition in these women.ConclusionPregnant and non-pregnant women undergoing breast surgery for cancer have similar short-term outcomes.     

Trends and determinants of stillbirth in developing countries: results from the Global Network’s Population-Based Birth Registry

Background

Stillbirth rates remain high, especially in low and middle-income countries, where rates are 25 per 1000, ten-fold higher than in high-income countries. The United Nations’ Every Newborn Action Plan has set a goal of 12 stillbirths per 1000 births by 2030 for all countries.

Methods

From a population-based pregnancy outcome registry, including data from 2010 to 2016 from two sites each in Africa (Zambia and Kenya) and India (Nagpur and Belagavi), as well as sites in Pakistan and Guatemala, we evaluated the stillbirth rates and rates of annual decline as well as risk factors for 427,111 births of which 12,181 were stillbirths.

Results

The mean stillbirth rates for the sites were 21.3 per 1000 births for Africa, 25.3 per 1000 births for India, 56.9 per 1000 births for Pakistan and 19.9 per 1000 births for Guatemala. From 2010 to 2016, across all sites, the mean stillbirth rate declined from 31.7 per 1000 births to 26.4 per 1000 births for an average annual decline of 3.0%. Risk factors for stillbirth were similar across the sites and included maternal age < 20 years and age > 35 years. Compared to parity 1–2, zero parity and parity > 3 were both associated with increased stillbirth risk and compared to women with any prenatal care, women with no prenatal care had significantly increased risk of stillbirth in all sites.

Conclusions

At the current rates of decline, stillbirth rates in these sites will not reach the Every Newborn Action Plan goal of 12 per 1000 births by 2030. More attention to the risk factors and treating the causes of stillbirths will be required to reach the Every Newborn Action Plan goal of stillbirth reduction.

Trial registration

NCT01073475.

     

Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality

Objective To evaluate gestation-specific risks of stillbirth, neonatal and post-neonatal mortality.
Design Retrospective analysis of 171,527 notified births (1989–1991) and subsequent infant survival at one year, from community child health records.
Setting Notifications from maternity units in the North East Thames Region, London.
Main outcome measures The incidence of births, stillbirths, neonatal and post-neonatal deaths at each gestation after 28 completed weeks. Mortality rates per 1000 total or live births and per 1000 ongoing pregnancies at each gestation were calculated.
Results The rates of stillbirth at term (2.3 per 1000 total births) and post-term (1.9 per 1000 total births) were similar. When calculated per 1000 ongoing pregnancies, the rate of stillbirth increased six-fold from 0.35 per 1000 ongoing pregnancies at 37 weeks to 2.12 per 1000 ongoing pregnancies at 43 weeks of gestation. Neonatal and post-neonatal mortality rates fell significantly with advancing gestation, from 15 1.4 and 31.7 per 1000 live births at 28 weeks, to reach a nadir at 41 weeks of gestation (0.7 and 1.3 per 1000 live births, respectively), increasing thereafter in prolonged gestation to 1.6 and 2.1 per 1000 live births at 43 weeks of gestation. When calculated per 1000 ongoing pregnancies, the overall risk of pregnancy loss (stillbirth + infant mortality) increased eight-fold from 0.7 per 1000 ongoing pregnancies at 37 weeks to 5.8 per 1000 ongoing pregnancies at 43 weeks of gestation.
Conclusion The risks of prolonged gestation on pregnancy are better reflected by calculating fetal and infant losses per 1000 ongoing pregnancies. There is a significant increase in the risk of stillbirth, neonatal and post-neonatal mortality in prolonged pregnancy. This study provides accurate data on gestation-specific risks of pregnancy loss, enabling pregnant women and their carers to judge the appropriateness of obstetric intervention.     

Maternal and Perinatal Outcomes of Extreme Obesity in Pregnancy

ObjectiveTo evaluate the effects of extreme obesity (pre-pregnancy BMI ≥ 50.0 kg/m²) in pregnancy on maternal and perinatal outcomes.MethodsWe conducted a population-based cohort study using the Newfoundland and Labrador Perinatal Database to compare obstetric outcomes in women with extreme obesity and those with a normal BMI (pre-pregnancy BMI 18.50 to 24.99 kg/m²). We included women with singleton gestations who gave birth between January 1, 2002, and December 31, 2011. Maternal outcomes of interest included gestational hypertension, gestational diabetes, Caesarean section, shoulder dystocia, length of hospital stay, maternal ICU admission, postpartum hemorrhage, and death. Perinatal outcomes included birth weight, preterm birth, Apgar score, neonatal metabolic abnormality, NICU admission, stillbirth, and neonatal death. A composite morbidity outcome was developed including at least one of Caesarean section, gestational hypertension, birth weight ≥ 4000 g, birth weight < 2500 g, or NICU admission. Univariate analyses and multivariate logistic regression analyses (controlling for maternal age, parity, smoking, partner status, and gestational age) were performed, and adjusted odds ratios (aORs) and 95% confidence intervals were calculated.ResultsA total of 5788 women were included in the study: 71 with extreme obesity and 5717 with a normal BMI. Extremely obese women were more likely to have gestational hypertension (19.7% vs.4.8%) (aOR 1.56; 95% CI 1.33 to 1.82), gestational diabetes (21.1% vs.1.5%) (aOR 2.04; 95% CI 1.74 to 2.38), shoulder dystocia (7.1% vs.1.4%) (aOR 1.51; 95% CI 1.05 to 2.19), Caesarean section (60.6% vs.25.0%) (aOR 1.46; 95% CI 1.29 to 1.65), length of hospital stay more than five days (excluding Caesarean section) (14.3% vs.4.7%) (aOR 1.42; 95% CI 1.07 to 1.89), birth weight ≥ 4000 g (38.0% vs. 11.9%) (aOR 1.58; 95% CI 1.38 to 1.80), birth weight ≥ 4500 g (16.9% vs.2.1%) (aOR 1.87; 95% CI 1.57 to 2.23), neonatal metabolic abnormality (8.5% vs.2.0%) (aOR 1.50; 95% CI 1.20 to 1.86), NICU admission (16.9% vs.7.8%) (aOR 1.28; 95% CI 1.07 to 1.52), stillbirth (1.4% vs.0.2%) (aOR 1.68; 95% CI 1.00 to 2.82) and composite adverse outcome (81.7% vs.41.5%) (aOR 1.57; 95% CI 1.35 to 1.83).ConclusionWomen with extreme obesity have increased risks of a variety of adverse maternal and perinatal outcomes. As approximately 6 per 1000 women giving birth in our population have extreme obesity, it is important to address these risks pre-conceptually and encourage a healthier BMI before pregnancy.     

Microalbuminuria is a predictor of adverse pregnancy outcomes including preeclampsia

ObjectivesAbnormal urinary protein loss is a marker associated with a diverse range of renal diseases including preeclampsia. Current measures of urine protein used in the diagnostic criteria for the diagnosis of preeclampsia includes urine protein:creatinine ratio and 24-h urine protein. However very little is known about the value of urine albumin:creatinine ratio (uACR) in pregnancy. In this study we examined the prognostic value of microalbuminuria detected antepartum to predict adverse pregnancy outcomes.DesignThis is a single-centre retrospective analysis of 84 pregnant women over the age of 16 attending a tertiary ‘high-risk’ pregnancy outpatient clinic between July 2010 and June 2013. Utilising medical records, antepartum peak uACR level and pregnancy maternal and fetal outcomes were recorded.FindingsThe primary outcome was a composite of poor maternal and fetal outcomes including preeclampsia, maternal death, eclampsia, stillbirth, neonatal death, IUGR, premature delivery and placental abruption. As the antepartum peak uACR level (in mg/mmol) increased from normoalbuminuria (uACR < 3.5) to microalbuminuria (uACR 3.5–35) to macroalbuminuria (>35), the percentage of women with the primary composite outcome increased in a stepwise fashion (13.8% to 24.1% to 62.1% respectively, p < 0.001). After adjusting for covariates including history of hypertension, chronic kidney disease and aspirin therapy during pregnancy, micro- and macroalbuminuria remained significant predictors of the primary outcome.ConclusionsWe have shown that antepartum peak uACR is a useful simple marker to help predict adverse maternal and fetal outcomes. Further studies are required to utilise uACR as a prognostic tool in pregnancy before it can be applied in clinical practice.     

The Effect of Maternal Age on Adverse Birth Outcomes: Does Parity Matter?

ObjectivesTo examine the effect of parity on the association between older maternal age and adverse birth outcomes, specifically stillbirth, neonatal death, preterm birth, small for gestational age, and neonatal intensive care unit admission.MethodsWe conducted a retrospective cohort study of singleton births in British Columbia between 1999 and 2004. In the cohort, 69 023 women were aged 20 to 29, 25 058 were aged 35 to 39, and 4816 were aged 40 and over. Perinatal risk factors, obstetric history, and birth outcomes were abstracted from the British Columbia Perinatal Database Registry. Logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals for adverse outcomes in the two older age groups compared with the young control subjects.ResultsCompared with younger control subjects, women aged 35 to 39 years had an aOR of stillbirth of 1.5 (95% CI 1.2 to 1.9) and women aged ≥ 40 years also had an aOR of 1.5 (95% CI 1.0 to 2.4). The aOR for NICU admission was 1.2 (95% CI 1.0 to 1.3) in women aged 35 to 39 years and 1.4 (95% CI 1.1 to 17) in women aged ≥ 40 years compared with younger control subjects. The risk of preterm birth and SGA differed by parity. The aOR for preterm birth compared with younger primiparas was 1.5 (95% CI 1.4 to 1.7) for women aged 35 to 39 years and 1.6 (95% CI 1.3 to 2.0) for women aged ≥ 40 years. In multiparas the aOR for preterm birth was 1.1 (95% CI 1.1 to 1.2) in women aged 35 to 39 and 1.3 (95% CI 1.1 to 1.5) in women > 40 years. The aOR for SGA in primiparas was 1.2 (95% CI 1.1 to 1.4) for women aged 35 to 39 and 1.4 (95% CI 1.1 to 1.7) for women aged ≥ 40 years. The risk of neonatal death was not significantly different between groups.ConclusionOlder women were at elevated risk of stillbirth, preterm birth, and NICU admission regardless of parity. Parity modified the effect of maternal age on preterm birth and SGA. Older primiparas were at elevated risk for SGA, but no association between age and SGA was found in multiparas. Older primiparas were at higher risk of preterm birth than older multiparas compared with younger women.     

Socio-economic and ethnic factors in stillbirth and neonatal mortality in the NE Thames Regional Health Authority (NETRHA) 1983

Summary. All stillbirths and neonatal deaths occurring in the North East Thames region were studied in 1983. This report describes the socio-economic and ethnic differences in that cohort. The stillbirth and neonatal mortality rates of babies born to fathers of social class V (16–8 per 1000 total births) was almost double that of social class I fathers (8–6 per 1000 total births). The most marked social class gradient was seen in the macerated stillbirth groups. Of particular concern was the extremely high stillbirth and neonatal mortality rate for women born in the Indian subcontinent. This was most evident in Pakistani women who had a stillbirth plus neonatal mortality rate of 17.3 per 1000 total births, almost twice that of the women born in the UK (9.0 per 1000 total births). Again, as with social class, macerated stillbirths appeared to contribute disproportionately to the excess mortality. Mortality rates were aggre gated into four birthweight specific groups. Asian women had higher mortality rates in the higher birthweight groups, whereas in the lower birthweight group their babies did slightly better. This study indicated that the special needs for working class and ethnic minority mothers within NE Thames were not being met, and the Regional Health Authority was strongly recommended to review services to these groups.     

Advancing obstetric and neonatal care in a regional hospital in Ghana via continuous quality improvement

ObjectiveTo reduce maternal and neonatal death at a large regional hospital through the use of quality improvement methodologies.MethodsIn 2007, Kybele and the Ghana Health Service formed a partnership to analyze systems and patient care processes at a regional hospital in Accra, Ghana. A model encompassing continuous assessment, implementation, advocacy, outputs, and outcomes was designed. Key areas for improvement were grouped into “bundles” based on personnel, systems management, and service quality. Primary outcomes included maternal and perinatal mortality, and case fatality rates for hemorrhage and hypertensive disorders. Implementation and outcomes were evaluated tri-annually between 2007 and 2009.ResultsDuring the study period, there was a 34% decrease in maternal mortality despite a 36% increase in patient admission. Case fatality rates for pre-eclampsia and hemorrhage decreased from 3.1% to 1.1% (P < 0.05) and from 14.8% to 1.9% (P < 0.001), respectively. Stillbirths were reduced by 36% (P < 0.05). Overall, the maternal mortality ratio decreased from 496 per 100 000 live births in 2007 to 328 per 100 000 in 2009.ConclusionMaternal and newborn mortality were reduced in a low-resource setting when appropriate models for continuous quality improvement were developed and employed.     

Socio-economic and ethnic factors in stillbirth and neonatal mortality in the NE Thames Regional Health Authority (NETRHA) 1983

All stillbirths and neonatal deaths occurring in the North East Thames region were studied in 1983. This report describes the socio-economic and ethnic differences in that cohort. The stillbirth and neonatal mortality rates of babies born to fathers of social class V (16.8 per 1000 total births) was almost double that of social class I fathers (8.6 per 1000 total births). The most marked social class gradient was seen in the macerated stillbirth groups. Of particular concern was the extremely high stillbirth and neonatal mortality rate for women born in the Indian subcontinent. This was most evident in Pakistani women who had a stillbirth plus neonatal mortality rate of 17.3 per 1000 total births, almost twice that of the women born in the UK (9.0 per 1000 total births). Again, as with social class, macerated stillbirths appeared to contribute disproportionately to the excess mortality. Mortality rates were aggregated into four birthweight specific groups. Asian women had higher mortality rates in the higher birthweight groups, whereas in the lower birthweight group their babies did slightly better. This study indicated that the special needs for working class and ethnic minority mothers within NE Thames were not being met, and the Regional Health Authority was strongly recommended to review services to these groups.     

Antepartum Risk Score Predicts Adverse Birth Outcomes

ObjectiveStandardized risk assessment plays an important role in providing medical care of uniform quality to pregnant women, even though it is not a substitute for clinical judgement. This study was designed to determine whether the antepartum risk score currently used across Alberta is associated with neonatal morbidity and adverse pregnancy outcomes for singleton live births and to examine whether the current classification of “lower risk” pregnancies (score < 3) is justified.MethodsA retrospective study was conducted of the delivery records for a cohort of all live singleton births in Alberta from 2001 to 2005 that contained a completed antenatal risk assessment. Adverse neonatal condition or pregnancy outcome was assessed by Apgar score, transfer of the infant to a neonatal intensive care unit, “serious” resuscitation measures, preterm birth, and low birth weight. The population-attributable fraction of any of the adverse outcomes was calculated.ResultsAll outcome measures except for NICU admissions were available for the entire 2001 to 2005 period (n = 191 686); NICU admissions were consistently recorded only from 2002 to 2005 (n = 154 924). The incidence of complications increased steadily as the risk score increased and increased more steeply above a score of 4. Approximately one third of the complications were associated with risk scores of between 2 and 6.ConclusionThe antepartum risk score currently used in Alberta is a useful tool for identifying women at higher risk of an adverse pregnancy outcome. Current categorization of pregnancies with an antepartum risk score of 2 as lower risk should be reconsidered in light of these findings.     

Trends in perinatal deaths from 2010 to 2013 in the Guatemalan Western Highlands

Background

While progress has been made in reducing neonatal mortality in Guatemala, stillbirth and maternal mortality rates remain high, especially among the indigenous populations, which have among the highest adverse pregnancy-related mortality rates in Guatemala.

Methods

We conducted a prospective study in the Western Highlands of Guatemala from 2010 through 2013, enrolling women during pregnancy with follow-up through 42-days postpartum. All pregnant women were identified and enrolled by study staff in the clusters in the Chimaltenango region for which we had 4 years of data. Enrolment usually occurred during the antenatal period; women were also visited following delivery and 42-days postpartum to collect outcomes. Measures of antenatal and delivery care were also obtained.

Results

Approximately four thousand women were enrolled annually (3,869 in 2010 to 4,570 in 2013). The stillbirth rate decreased significantly, from 22.0 per 1000 births (95% CI 16.6, 29.0) in 2010 to 16.7 (95% CI 13.5, 20.6) in 2013 (p-value 0.0223). The perinatal mortality rate decreased from 43.9 per 1,000 births (95% CI 36.0, 53.6) to 31.6 (95% CI 27.2, 36.7) (p-value 0.0003). The 28-day neonatal mortality rate decreased from 28.9 per 1000 live births (95% CI 25.2, 33.2) to 21.7 (95% CI 17.5, 26.9), p-value 0.0004. The maternal mortality rate was 134 per 100,000 in 2010 vs. 113 per 100,000 in 2013. Over the same period, hospital birth rates increased from 30.0 to 50.3%.

Conclusions

In a relatively short time period, significant improvements in neonatal, fetal and perinatal mortality were noted in an area of Guatemala with a history of poor pregnancy outcomes. These changes were temporally related to major increases in hospital-based delivery with skilled birth attendants, as well as improvements in the quality of delivery care, neonatal care, and prenatal care.

     

Influence of early self-diagnosis and treatment of bacterial vaginosis on preterm birth rate

ObjectiveTo assess whether early self-diagnosis and treatment of bacterial vaginosis (BV) could lower the preterm birth rate among a group of Indonesian women.MethodsA randomized controlled trial of 331 pregnant women (14–18 weeks) was conducted. Participants were randomly assigned to either the active model group (n = 176) or the control group (n = 155). Women in the active model group were equipped with a kit to self-evaluate vaginal pH; those with a positive test result were treated with a twice daily dose of 500 mg of metronidazole for 7 days. The primary end point was preterm birth rate.ResultsThere were 6 (3.8%) and 8 (5.4%) preterm births in the active model and control groups, respectively (P = 0.468). No spontaneous abortions were recorded in either group. When compared with the gold standard (Gram staining), the vaginal acidity test had low ability to detect BV, with 88.7% specificity and 36.9% sensitivity. The positive predictive value of the test was 35.0% PPV, while the negative predictive value was 89.4%.ConclusionEarly self-diagnosis and treatment of BV did not reduce the preterm birth rate of the study group.ClinicalTrial.gov number: NCT01232192.     

Changes in Smoking During Pregnancy in Ontario, 1995 to 2010: Results From the Canadian Community Health Survey

ObjectiveThe objectives of this study were (1) to examine changes in smoking behaviour across time in pregnant women in Ontario (relative to non-pregnant women and men) and (2) to assess whether, among pregnant women, changes across time vary as a function of sociodemographic characteristics.MethodsThis study used data from the Canadian Community Health Survey. The study sample included 15- to 49-year-old residents of Ontario. Multivariable logistic regression, with interactions between time period and the characteristic of interest, was used to examine whether changes varied across time according to (1) group (pregnant women, non-pregnant women, men; two-year intervals, 2001 to 2010) and (2) pregnant subgroup (maternal age, maternal marital status, maternal education; 1995 to 2000 [n = 3745], 2001 to 2005 [n = 5084], and 2006 to 2010 [n = 2900]).ResultsA decrease in the prevalence of smoking across time was seen in all groups but was smaller in pregnant women than in non-pregnant women (23.5% vs. 30.8%). Among pregnant women, interactions between time period and maternal age, maternal marital status, and maternal education were statistically significant. The prevalence of smoking during pregnancy decreased in older, married, and more highly educated women, but increased in younger women (by 8.2%) and less educated women (by 12.8%). Although the prevalence of smoking during pregnancy decreased in unmarried women, the change was smaller than in married women.ConclusionAlthough the prevalence of smoking in pregnant women is decreasing over time, the decrease is smaller than that in non-pregnant women. Pregnant subgroups particularly resistant to change include younger, unmarried, and less educated mothers. These findings suggest there are subgroups that should be targeted more deliberately by public health interventions.     

Prenatal Smoking among Adolescents and Risk of Fetal Demise before and during Labor

Study ObjectiveTo investigate the relationship between smoking during pregnancy and the occurrence of stillbirth phenotypes among adolescent mothers.DesignRetrospective cohortSettingSingleton births in Missouri from 1978 through 1997.ParticipantsTwo groups of “younger” (<15 years) and “older” (15–19 years) adolescent mothers were compared to “mature” mothers (age 20–24 years).Main Outcome MeasuresCox Proportional Hazards Regression models generated adjusted risk estimates of the association between intrauterine nicotine exposure and the risk of total, antepartum, and intrapartum stillbirth in each age group.ResultsApproximately 32% (N = 205,887) of the total 633,849 singleton births analyzed were among adolescent mothers. The overall prevalence of smoking was 31.2%, with the lowest prevalence (14.1%) among the youngest mothers while older adolescents had the highest (31.7%). The risk for intrapartum stillbirth among smoking adolescents <15 years of age was twice the risk for older adolescent and mature mothers. The risk of intrapartum stillbirth among smokers decreased as maternal age increased: [adjusted hazard ratio (AHR), 95% confidence interval (CI) for young mothers: 4.0, 95%CI = 0.6–28.7; for older adolescents AHR = 1.5, 95%CI = 1.1–2.1 and for mature mothers AHR = 1.8, 95% CI = 1.4–2.2], respectively.ConclusionsIn utero tobacco exposure has maternal age-related differential and lethal effects on the fetus. Young maternal age tends to potentiate these effects. There is a public health need to develop appropriate smoking cessation messages targeted specifically to this high risk group.     

A cross-sectional study of female sexual function and dysfunction during pregnancy

IntroductionAlthough women may undergo changes in sexual function during pregnancy, there are limited studies correlating possible sexual function changes to androgen blood levels during the pregnancy.AimTo search for a possible correlation, we performed a cross-sectional observational study to assess sexual function scores and androgen blood levels of women during pregnancy.Materials and MethodsA total of 589 healthy pregnant women were recruited to the present cross-sectional study. Of these patients, 116 (19.6%), 220 (37.3%), and 253 (42.9%) were in their first, second, and third trimesters, respectively. They were evaluated with a detailed medical and sexual history, including IFSF questionnaire. In addition, maternal serum androgen levels (testosterone, dehydroepiandrosterone sulphate, free testosterone) were determined in each trimester during regular follow-ups.Main Outcome MeasuresAssessment of Index of Female Sexual Function (IFSF) domains and serum androgen levels in each trimester.ResultsThe mean age of the three groups were similar (P > 0.05). Overall, total IFSF scores of women in the first and second trimesters were 21.4 ± 10.1 and 22.3 ± 10, respectively, while it was 15.9 ± 12.3 during the third trimester (P < 0.05). The most common sexual dysfunction symptom was diminished clitoral sensation, observed in 94.2% of the patients, followed by lack of libido in 92.6% and orgasmic disorder in 81%. No correlation was detected between total IFSF score and serum androgen levels.ConclusionsIn this cross-sectional study, we noted lower sexual function scores in women in the third trimester of their pregnancies compared with those in their first two trimesters of pregnancy. These lower sexual function scores in the third trimester were not associated with lower androgen levels. We plan to perform a future prospective study to better assess both the change in sexual function and also its possible relation to androgen levels in pregnant women. Erol B, Sanli O, Korkmaz D, Seyhan A, Akman T, and Kadioglu A. A cross-sectional study of female sexual function and dysfunction during pregnancy.     

Impact de la chirurgie bariatrique sur le pronostic obstétrical

ObjectivesAssessment of pregnancy outcomes after bariatric surgery and analysis of follow-up particularities of such pregnancies.Patients and methodsA retrospective study of 63 post-bariatric surgery pregnancies compared to 259 pregnancies of obese un-operated patients. Pregnancy outcomes, neonatal datas, delay influence between surgery and pregnancy beginning, bariatric surgery type and gastric banding (GB) loosening consequences were analysed.ResultsIn the surgical brand were developed less gestational diabetes (DG) (P = 0,05), deliveries were more often normal (P = 0,004) and births shown less macrosomias and small for gestational age newborns (P = 0,04). Neonatal state was improved among operated patients: less Apgar scores less than 7 at 1 minute (P = 0,05) and less cord blood pH less than 7,2 (P = 0,03). They gained more weight during the pregnancy (P = 0,0003) and only 53% had a nutritional management and assessment. Patients with GB loosening gained more weight (P = 0,0003). Lastly, there were no difference due to the different bariatric surgery techniques or nutritional follow-up in the pregnancy course and neonatal state.Discussion and conclusionBariatric surgery improves obstetric and neonatal prognosis. Improvements have to be developed in the multidisciplinary follow-up in order to avoid nutritional deficiencies or important weight gain pregnancy in case of GB.     

Adverse maternal and fetal outcomes and deaths related to preeclampsia and eclampsia in Haiti

ObjectiveThe purpose of this study was to define the prevalence and clinical characteristics of preeclampsia and eclampsia at a hospital in rural Haiti.MethodsThis is a retrospective review of women presenting to Hôpital Albert Schweitzer (HAS) in Deschapelles, Haiti with singleton pregnancy and diagnosis of preeclampsia or eclampsia from January 1, 2011 through December 31, 2012. Hospital charts were reviewed to obtain medical and prenatal history, hospital course, delivery information, and fetal/neonatal outcomes. The outcomes included placental abruption, antepartum eclampsia, postpartum eclampsia, maternal death, birthweight <2500 g and stillbirth. Data are presented as median (quartile 1, quartile 3) or n (%) and risk ratios.ResultsDuring the study period, 1743 women were admitted to the maternity service at HAS and 290 (16.6%) were diagnosed with preeclampsia or eclampsia. Only singleton pregnancies were analyzed (N = 270). Nearly all (95.0%) patients admitted with preeclampsia had severe preeclampsia. There were 83 patients with eclampsia (30.7%) of which 61 (73.4%) had antepartum eclampsia. There were 48 stillbirths (17.8%) and 5 maternal deaths (1.9%). Patients with antepartum eclampsia were younger, more likely to be nulliparous and had less prenatal care compared to women with antepartum preeclampsia. Antepartum eclampsia was associated with placental abruption and maternal death.ConclusionsThe rates of preeclampsia and its associated complications, such as eclampsia, placental abruption, maternal death and stillbirth, are high at this facility in Haiti. Such data are essential to developing region-specific systems to prevent preeclampsia-related complications.     

Validity of umbilical artery Doppler waveform versus umbilical vein Doppler waveform in the prediction of neonatal outcome in intrauterine growth restriction cases

ObjectiveTo assess the neonatal outcome in relation to umbilical vein Doppler compared to umbilical artery Doppler in growth restricted fetuses.MethodsA total of 72 pregnant women with singleton pregnancy between 28 and 38 weeks of gestation with risk of developing intrauterine growth restriction (IUGR) were recruited to the study. All women were subjected to full assessment via detailed history, clinical examination, obstetric assessment, routine laboratory assessment and ultrasonography examination for fetal assessment. Doppler examination of umbilical artery (UA) and umbilical vein (UV) was performed. Absent or reversed UA end diastolic flow (EDF) and pulsatile flow in the umbilical vein were examined for their efficacy to predict critical outcomes (still birth, neonatal death, IUGR).ResultsA total of 13 deaths (18%) were reported; 13.9% were neonatal deaths and 4.2% were stillbirths. Fetuses were grouped according to Doppler parameters: those with normal Doppler finding (n = 35), those with resistance index (RI) (n = 20), those with Absent UA EDF (n = 10) and those with reversed UA EDF (n = 7). Pulsatile UV waveform was reported among 9.7% of patients all of them had reversed UA EDF. Patients with absent/reversed EDF have significant association with critical neonatal outcomes as lower birth weight, perinatal deaths, and lower Apgar score. UV Doppler was abnormal in patients with more severe deterioration (patients with reversed UA EDF) while it was normal in all patients with increased RI and absent UA EDF. All cases with Pulsatile UV Doppler have shown higher incidence of critical neonatal outcomes.ConclusionUV Doppler assessment can aid in detection and prediction of critical perinatal outcomes however, it required further evaluation and assessment.     

First-trimester maternal serum 25-hydroxyvitamin D3 status and pregnancy outcome

ObjectiveTo determine the pregnancy outcome as a function of the first-trimester serum 25-hydroxyvitamin D₃ [25(OH)D] status and to compare the 25(OH)D levels in the first and third trimesters.MethodsPregnant women (n = 466) tested for serum 25(OH)D levels during the first trimester were followed up until the end of pregnancy, and the obstetric and neonatal outcomes were compared in reference to the baseline 25(OH)D status. The third-trimester 25(OH)D levels were additionally measured in a subset of women (n = 148).ResultsThe obstetric and neonatal outcomes did not vary as a function of the first-trimester 25(OH)D status. Neither did the 25(OH)D levels vary as a function of pregnancy outcomes. Overall, the 25(OH)D levels significantly decreased from the first to the third trimester. The first- and third-trimester 25(OH)D levels of samples initially taken during autumn/winter were significantly lower than those that were initially taken during spring/summer. Interestingly, the decrease in 25(OH)D levels during the third trimester was independent of the season of sampling.ConclusionThe pregnancy outcome was independent of the first-trimester 25(OH)D status. Overall, the 25(OH)D levels significantly decreased in the third trimester. More research in this area is warranted.